Oligo-benzamide compounds and their use

ABSTRACT

The present invention includes bis- and tris-benzamide compounds that block AR signaling and have anticancer activity. Uses for these compounds, and pharmaceutical compositions containing the same, also are provided.

CROSS-REFERENCE TO RELATED APPLICATION

This application is a continuation of U.S. application Ser. No.14/932,480, filed Nov. 4, 2015, now U.S. Pat. No. 9,856,206, which is acontinuation of U.S. application Ser. No. 13/700,500, filed May 20,2013, now abandoned, which is a national phase application under 35U.S.C. § 371 of International Application No. PCT/US2011/038395, filedMay 27, 2011, which claims benefit of priority to U.S. ProvisionalApplication Ser. No. 61/349,555, filed May 28, 2010. Each of theseapplications is incorporated herein by reference.

FIELD OF THE INVENTION

The present invention relates in general to the field of peptidomimeticsand specifically to compositions of matter, kits, methods of makingoligo-benzamide peptidomimetic compounds, and methods of their use inmedical indications such as cancer.

BACKGROUND OF THE INVENTION

Androgen receptor (AR) signaling is essential for prostate cancerdevelopment, growth, and progression at all stages of disease. ARsignaling occurs via both genomic and non-genomic pathways and ismediated by AR interaction with cofactors including a scaffoldingprotein PELP-1. Recently, the inventors have discovered that PELP-1interacts with AR and that this interaction is critical for bothAR-mediated genomic and non-genomic signaling. Thus, they hypothesizethat disruption of the interaction of AR and PELP-1 may influenceAR-signaling.

Peptidomimetics (also known as peptide mimetics) are small organicmolecules that do not possess the peptide backbone structure, howeverstill retain a capability to interact with the same target protein byarranging essential functional groups (i.e., pharmacophores) in arequired three-dimensional pattern complimentary to a binding pocket inthe protein. Since peptides and proteins adopt and utilize secondarystructures (e.g., α-helix, β-sheet, and reverse turns) to make theirglobal shapes and to recognize their binding partners, rational designof secondary structure mimetics is an important strategy in developingsmall molecule modulators for protein complex formation, compared toconventional high-throughput screening of a chemical library.

At present, no compounds are known that specifically inhibit theinteraction with PELP-1 and AR. The identification of such compounds,and assessment of their use as anti-cancer agents, would therefore behighly desirable.

SUMMARY OF THE INVENTION

The present inventors recognized a need for stable small moleculespossessing the capability to modulate AR signaling without thelimitations of the peptide structure. The present invention provides aclass of small molecules that are stable and capable of interacting withmolecules involved in AR signaling but lacking the limitations of thepeptide structure. These small molecules include α-helix mimetics thatrepresent helical segments in the target molecules.

The oligo-benzamide peptidomimetic compound includes at least twooptionally substituted benzamides, with each of the substitutedbenzamides having one substituent on a benzene ring. The oligo-benzamidepeptidomimetic compound modulates protein-protein, protein-peptide, orprotein-drug interaction to exert a variety of physiologicalconsequences.

Another embodiment of the present invention is the addition of a thirdoptionally substituted benzamide connected to one of the at least twooptionally substituted benzamides, and the third optionally substitutedbenzamide may include one substituent on a benzene ring. The presentinvention also provides an oligo-benzamide peptidomimetic compound thatincludes at least two optionally substituted benzamides with onesubstituent on a benzene ring.

The present invention provides, in one aspect, a compound of formulas(A) or (B):

wherein:

-   -   R₁ and R₂ are each independently C₁-C₁₀ alkyl, C₁-C₁₀ alkenyl,        C₁-C₁₀ alkynyl, C₁-C₁₅ optionally substituted arylalkyl,        —(CH₂)_(n)—COOR, —(CH₂)_(n)—CONRR′, —(CH₂)_(n)—NRR′,        —(CH₂)_(n)—NH(C═NH)NRR′, —(CH₂)_(n)—NRCOR′, —(CH₂)_(n)—NRCOOR′,        —(CH₂)_(n)—OR, —(CH₂)_(n)—SR, —(CH₂)_(n)—SO_(m)R,        —(CH₂)_(n)—PO_(m)R, wherein n and m may be any number between 0        and 6 and R and R′ may be a H, C₁-C₁₀ alkyl, C₁-C₁₀ alkenyl,        C₁-C₁₀ alkynyl, or C₁-C₁₅ optionally substituted arylalkyl        group;    -   X is —NO₂ or —NHC(O)CH₂R₃, wherein R₃ is —NO₂, —Z, C₁-C₁₀ alkyl,        C₁-C₁₀ alkenyl, C₁-C₁₀ alkynyl, or C₁-C₁₅ arylalkyl, each of        which is optionally substituted with —COOR, —CONRR′, —NRR′,        —NH(C═NH)NRR′, —NRCOR′, —NRCOOR′, —OR, —SR, —SO_(n)R, or        —PO_(m)R, wherein n may be any number between 0 and 6 and R and        R′ may be a H, C₁-C₁₀ alkyl, C₁-C₁₀ alkenyl, C₁-C₁₀ alkynyl, or        C₁-C₁₅ optionally substituted arylalkyl group, and wherein Z is:

and

-   -   Y is —(CH₂)_(n)COOR₄, —(CH₂)_(n)CONR₄R₅, —(CH₂)_(n)NR₄R₅,        —(CH₂)_(n)—NR₄R₅, —(CH₂)_(n)—NH(C═NH)NR₄R₅, —(CH₂)_(n)—NR₄COR₅,        —(CH₂)_(n)—NR₄COOR₅, —(CH₂)_(n)—OR₄, —(CH₂)_(n)—SR₄,        —(CH₂)_(n)—SO_(m)R₄, —(CH₂)_(n)—PO_(m)R₄, wherein n and m may be        any number between 0 and 6,    -   R₄ and R₅ are independently selected from —H, C₁-C₁₀ alkyl,        C₁-C₁₀ alkenyl, C₁-C₁₀ alkynyl, or C₁-C₁₅ optionally substituted        arylalkyl group; or

wherein:

-   -   R₁, R₂ and R₃ are each independently C₁-C₁₀ alkyl, C₁-C₁₀        alkenyl, C₁-C₁₀ alkynyl, C₁-C₁₅ optionally substituted        arylalkyl, —(CH₂)_(n)—COOR, —(CH₂)_(n)—CONRR′, —(CH₂)_(n)—NRR′,        —(CH₂)_(n)—NH(C═NH)NRR′, —(CH₂)_(n)—NRCOR′, —(CH₂)_(n)—NRCOOR′,        —(CH₂)_(n)—OR, —(CH₂)_(n)—SR, —(CH₂)_(n)—SO_(m)R,        —(CH₂)_(n)—PO_(m)R, wherein n and m may be any number between 0        and 6 and R and R′ may be a H, C₁-C₁₀ alkyl, C₁-C₁₀ alkenyl,        C₁-C₁₀ alkynyl, or C₁-C₁₅ optionally substituted arylalkyl group        or

-   -   X′ is —NO₂ or —NHC(O)CH₂R₃, wherein R₃ is —NO₂, —Z′, C₁-C₁₀        alkyl, C₁-C₁₀ alkenyl, C₁-C₁₀ alkynyl, or C₁-C₁₅ arylalkyl, each        of which is optionally substituted with —COOR, —CONRR′, —NRR′,        —NH(C═NH)NRR′, —NRCOR′, —NRCOOR′, —OR, —SR, —SOUR, or —POUR,        wherein n may be any number between 0 and 6 and R and R′ may be        a H, C₁-C₁₀ alkyl, C₁-C₁₀ alkenyl, C₁-C₁₀ alkynyl, or C₁-C₁₅        optionally substituted arylalkyl group, and wherein Z′ is:

and

-   -   Y′ is —(CH₂)_(n)COOR₄, —(CH₂)_(n)CONR₄R₅, —(CH₂)_(n)NR₄R₅,        —(CH₂)_(n)—NR₄R₅, —(CH₂)_(n)—NH(C═NH)NR₄R₅, —(CH₂)_(n)—NR₄COR₅,        —(CH₂)_(n)—NR₄COOR₅, —(CH₂)_(n)—OR₄, —(CH₂)_(n)—SR₄,        —(CH₂)_(n)—SO_(m)R₄, —(CH₂)_(n)—PO_(m)R₄, wherein n and m may be        any number between 0 and 6,    -   R₄ and R₅ are independently selected from —H, C₁-C₁₀ alkyl,        C₁-C₁₀ alkenyl, C₁-C₁₀ alkynyl, or C₁-C₁₅ optionally substituted        arylalkyl group.

In particular, X may be —NO₂, and may further be defined as:

-   -   R₁ and R₂ are C₁-C₁₀ alkyl, C₁-C₁₀ alkenyl, or C₁-C₁₀ alkynyl;    -   R₁ and R₂ are optionally substituted C₁-C₁₅ arylalkyl;    -   R₁ and R₂ are —(CH₂)_(n)—NRR′ or —(CH2)_(n)-NH(C═NH)NRR′ groups,        wherein n may be any number between 0 and 6 and R and R′ may be        a H, C₁-C₁₀ alkyl, C₁-C₁₀ alkenyl, C₁-C₁₀ alkynyl, or C₁-C₁₅        optionally substituted arylalkyl;    -   R₁ and R₂ are —(CH₂)_(n)—COOR, —(CH₂)_(n)—CONRR′,        —(CH₂)_(n)—NRCOR′, —(CH₂)_(n)—NRCOOR′, —(CH₂)_(n)—SO_(m)R,        —(CH₂)_(n)—PO_(m)R, wherein n and m may be any number between 0        and 6 and R and R′ may be a H, C₁-C₁₀ alkyl, C₁-C₁₀ alkenyl,        C₁-C₁₀ alkynyl, or C₁-C₁₅ optionally substituted arylalkyl;    -   R₁ and R₂ are —(CH₂)_(n)—OR, —(CH₂)_(n)—SR, wherein R may be a        H, C₁-C₁₀ alkyl, C₁-C₁₀ alkenyl, C₁-C₁₀ alkynyl, or C₁-C₁₅        optionally substituted arylalkyl;    -   R₁ is C₁-C₁₅ optionally substituted arylalkyl, and R₂ is C₁-C₁₀        alkyl, C₁-C₁₀ alkenyl, or C₁-C₁₀ alkynyl;    -   R₁ is C₁-C₁₀ alkyl, C₁-C₁₀ alkenyl, or C₁-C₁₀ alkynyl, and R₂ is        C₁-C₁₅ optionally substituted arylalkyl;    -   R₁ is —(CH₂)_(n)—NRR′ or —(CH2)_(n)-NH(C═NH)NRR′, and R₂ is        —(CH₂)_(n)—COOR, —(CH₂)_(n)—SO_(m)R, —(CH₂)_(n)—PO_(m)R, wherein        n and m may be any number between 0 and 6 and R and R′ may be a        H, C₁-C₁₀ alkyl, C₁-C₁₀ alkenyl, C₁-C₁₀ alkynyl, or C₁-C₁₅        optionally substituted arylalkyl group;    -   R₁ is —(CH₂)_(n)—COOR, —(CH₂)_(n)—SO_(m)R, —(CH₂)_(n)—PO_(m)R,        and R₂ is —(CH₂)_(n)—NRR′ or —(CH2)_(n)-NH(C═NH)NRR′, wherein n        and m may be any number between 0 and 6 and R and R′ may be a H,        C₁-C₁₀ alkyl, C₁-C₁₀ alkenyl, C₁-C₁₀ alkynyl, or C₁-C₁₅        optionally substituted arylalkyl group; or    -   R₁ or R₂ are independently selected from isopropyl, isobutyl,        n-butyl, sec-butyl or n-pentyl.

In particular, X′ may be —NO₂, and may further be defined as:

-   -   R₁, R₂, and R₃ are C₁-C₁₀ alkyl, C₁-C₁₀ alkenyl, or C₁-C₁₀        alkynyl;    -   R₁, R₂, and R₃ are optionally substituted C₁-C₁₅ arylalkyl;    -   R₁, R₂, and R₃ are —(CH₂)_(n)—NRR′ or —(CH2)_(n)-NH(C═NH)NRR′        groups, wherein n may be any number between 0 and 6 and R and R′        may be a H, C₁-C₁₀ alkyl, C₁-C₁₀ alkenyl, C₁-C₁₀ alkynyl, or        C₁-C₁₅ optionally substituted arylalkyl;    -   R₁, R₂, and R₃ are —(CH₂)_(n)—COOR, —(CH₂)_(n)—CONRR′,        —(CH₂)_(n)—NRCOR′, —(CH₂)_(n)—NRCOOR′, —(CH₂)_(n)—SO_(m)R,        —(CH₂)_(n)—PO_(m)R, wherein n and m may be any number between 0        and 6 and R and R′ may be a H, C₁-C₁₀ alkyl, C₁-C₁₀ alkenyl,        C₁-C₁₀ alkynyl, or C₁-C₁₅ optionally substituted arylalkyl;    -   R₁, R₂, and R₃ are —(CH₂)_(n)—OR, —(CH₂)_(n)—SR, wherein R may        be a H, C₁-C₁₀ alkyl, C₁-C₁₀ alkenyl, C₁-C₁₀ alkynyl, or C₁-C₁₅        optionally substituted arylalkyl;    -   R₁ is C₁-C₁₅ optionally substituted arylalkyl, and R₂ and R₃ are        C₁-C₁₀ alkyl, C₁-C₁₀ alkenyl, or C₁-C₁₀ alkynyl;    -   R₁ and R₂ are C₁-C₁₀ alkyl, C₁-C₁₀ alkenyl, or C₁-C₁₀ alkynyl,        and R₃ is C₁-C₁₅ optionally substituted arylalkyl;    -   R₁ is C₁-C₁₀ alkyl, C₁-C₁₀ alkenyl, or C₁-C₁₀ alkynyl, and R₂        and R₃ are C₁-C₁₅ optionally substituted arylalkyl;    -   R₁ and R₂ are C₁-C₁₅ optionally substituted arylalkyl, and R₃ is        C₁-C₁₀ alkyl, C₁-C₁₀ alkenyl, or C₁-C₁₀ alkynyl;    -   R₁ and R₃ are C₁-C₁₀ alkyl, C₁-C₁₀ alkenyl, or C₁-C₁₀ alkynyl,        and R₂ is C₁-C₁₅ optionally substituted arylalkyl;    -   R₁ and R₃ are C₁-C₁₅ optionally substituted arylalkyl, and R₂ is        C₁-C₁₀ alkyl, C₁-C₁₀ alkenyl, or C₁-C₁₀ alkynyl;    -   R₁ and R₂ are —(CH₂)_(n)—NRR′ or —(CH2)_(n)-NH(C═NH)NRR′, and R₃        is C₁-C₁₀ alkyl, C₁-C₁₀ alkenyl, or C₁-C₁₀ alkynyl, wherein n        may be any number between 0 and 6 and R and R′ may be a H,        C₁-C₁₀ alkyl, C₁-C₁₀ alkenyl, C₁-C₁₀ alkynyl, or C₁-C₁₅        optionally substituted arylalkyl;    -   R₁ is C₁-C₁₀ alkyl, C₁-C₁₀ alkenyl, or C₁-C₁₀ alkynyl, and R₂        and R₃ are —(CH₂)_(n)—NRR′ or —(CH2)_(n)-NH(C═NH)NRR′, wherein n        may be any number between 0 and 6 and R and R′ may be a H,        C₁-C₁₀ alkyl, C₁-C₁₀ alkenyl, alkynyl, or C₁-C₁₅ optionally        substituted arylalkyl;    -   R₁ and R₂ are —(CH₂)_(n)—NRR′ or —(CH2)_(n)-NH(C═NH)NRR′, and R₃        is C₁-C₁₅ optionally substituted arylalkyl, wherein n may be any        number between 0 and 6 and R and R′ may be a H, C₁-C₁₀ alkyl,        C₁-C₁₀ alkenyl, C₁-C₁₀ alkynyl, or C₁-C₁₅ optionally substituted        arylalkyl;    -   R₁ is C₁-C₁₅ optionally substituted arylalkyl, and R₂ and R₃ are        —(CH₂)_(n)—NRR′ or —(CH2)_(n)-NH(C═NH)NRR′, wherein n may be any        number between 0 and 6 and R and R′ may be a H, C₁-C₁₀ alkyl,        C₁-C₁₀ alkenyl, alkynyl, or C₁-C₁₅ optionally substituted        arylalkyl;    -   R₁ and R₂ are —(CH₂)_(n)—COOR, —(CH₂)_(n)—CONRR′,        —(CH₂)_(n)—NRCOR′, —(CH₂)_(n)—NRCOOR′, —(CH₂)_(n)—SO_(m)R,        —(CH₂)_(n)—PO_(m)R, and R₃ is C₁-C₁₀ alkyl, C₁-C₁₀ alkenyl, or        C₁-C₁₀ alkynyl, wherein n and m may be any number between 0 and        6 and R and R′ may be a H, C₁-C₁₀ alkyl, C₁-C₁₀ alkenyl, C₁-C₁₀        alkynyl, or C₁-C₁₅ optionally substituted arylalkyl;    -   R₁ is C₁-C₁₀ alkyl, C₁-C₁₀ alkenyl, or C₁-C₁₀ alkynyl, and R₂        and R₃ are —(CH₂)_(n)—COOR, —(CH₂)_(n)—CONRR′,        —(CH₂)_(n)—NRCOR′, —(CH₂)_(n)—NRCOOR′, —(CH₂)_(n)—SO_(m)R,        —(CH₂)_(n)—PO_(m)R, wherein n and m may be any number between 0        and 6 and R and R′ may be a H, C₁-C₁₀ alkyl, C₁-C₁₀ alkenyl,        C₁-C₁₀ alkynyl, or C₁-C₁₅ optionally substituted arylalkyl;    -   R₁ and R₂ are —(CH₂)_(n)—COOR, —(CH₂)_(n)—CONRR′,        —(CH₂)_(n)—NRCOR′, —(CH₂)_(n)—NRCOOR′, —(CH₂)_(n)—SO_(m)R,        —(CH₂)_(n)—PO_(m)R, and R₃ is C₁-C₁₅ optionally substituted        arylalkyl, wherein n and m may be any number between 0 and 6 and        R and R′ may be a H, C₁-C₁₀ alkyl, C₁-C₁₀ alkenyl, alkynyl, or        C₁-C₁₅ optionally substituted arylalkyl;    -   R₁ is C₁-C₁₅ optionally substituted arylalkyl, and R₂ and R₃ are        —(CH₂)_(n)—COOR, —(CH₂)_(n)—CONRR′, —(CH₂)_(n)—NRCOR′,        —(CH₂)_(n)—NRCOOR′, —(CH₂)_(n)—SO_(n)R, —(CH₂)_(n)—PO_(m)R,        wherein n and m may be any number between 0 and 6 and R and R′        may be a H, C₁-C₁₀ alkyl, C₁-C₁₀ alkenyl, alkynyl, or C₁-C₁₅        optionally substituted arylalkyl;    -   R₁ and R₃ are —(CH₂)_(n)—NRR′ or —(CH2)_(n)—NH(C═NH)NRR′, and R₂        is —(CH₂)_(n)—COOR, —(CH₂)_(n)—CONRR′, —(CH₂)_(n)—NRCOR′,        —(CH₂)_(n)—NRCOOR′, —(CH₂)_(n)—SO_(m)R, —(CH₂)_(n)—PO_(m)R,        wherein n and m may be any number between 0 and 6 and R and R′        may be a H, C₁-C₁₀ alkyl, C₁-C₁₀ alkenyl, C₁-C₁₀ alkynyl, or        C₁-C₁₅ optionally substituted arylalkyl;    -   R₁ and R₃ are —(CH₂)_(n)—COOR, —(CH₂)_(n)—CONRR′,        —(CH₂)_(n)—NRCOR′, —(CH₂)_(n)—NRCOOR′, —(CH₂)_(n)—SO_(m)R,        —(CH₂)_(n)—PO_(m)R, and R₂ is —(CH₂)_(n)—NRR′ or        —(CH2)_(n)-NH(C═NH)NRR′, wherein n and m may be any number        between 0 and 6 and R and R′ may be a H, C₁-C₁₀ alkyl, C₁-C₁₀        alkenyl, C₁-C₁₀ alkynyl, or C₁-C₁₅ optionally substituted        arylalkyl;    -   R₁, R₂ or R₃ are independently selected from isopropyl,        isobutyl, n-butyl, sec-butyl or n-pentyl; or    -   R₁, R₂ or R₃ is:

Alternatively, X may be —NHC(O)CH₂R₃ and R₃ may be —NH₂ or C₁-C₁₀ alkyl,optionally substituted with —COOH. Alternatively, X′ may be—NHC(O)CH₂NH₂.

Y or Y′ may in particular be —NH₂.

Specific compound according to the invention include:

Also provided is a pharmaceutical composition comprising any of thecompounds described above, dispersed in a pharmaceutically acceptablecarrier, buffer or diluent.

In another embodiment, there is provided a method of inhibiting aandrogen receptor (AR)-positive tumor cell in a subject comprisingadministering to said subject a therapeutically sufficient amount of anoligo-benzamide peptidomimetic compound as described above.

The AR-positive tumor cell may be a carcinoma cell, a leukemia cell or amyeloma cell. The carcinoma cell may be a prostate or breast carcinomacell. The peptidomimetic may be fused to a cell delivery domain.Administering may comprise intravenous, intra-arterial, intra-tumoral,subcutaneous, topical or intraperitoneal administration, or local,regional, systemic, or continual administration. Inhibiting may compriseinducing growth arrest of said tumor cell, apoptosis of said tumor celland/or necrosis of a tumor tissue comprising said tumor cell.

Administering may further comprise providing a second anti-cancertherapy, such as surgery, chemotherapy, radiotherapy, hormonal therapy,toxin therapy, immunotherapy, and cryotherapy. The may be provided priorto administration of said compound, after administration of saidcompound, or at the same time as said compound.

The subject may be a human. The compound may be is administered at about0.1 to 100 mg/kg or at about 1 to about 50 mg/kg, or at about 10 mg/kg.The compound may be administered daily, for example, for 7 days, 2weeks, 3 weeks, 4 weeks, one month, 6 weeks, 8 weeks, two months, 12weeks, or 3 months. The compound may be administered weekly, forexample, for 2 weeks, 3 weeks, 4 weeks, 6 weeks, 8 weeks, 10 weeks, or12 weeks.

The method may further comprise assessing AR-driven gene expression insaid tumor cell of said subject prior to administering said compound, orfurther comprise assessing AR-driven gene expression in said tumor cellof said subject after administering said compound.

The present invention provides a pharmaceutical composition thatincludes a therapeutically effective amount of an oligo-benzamidecompound or a salt, a solvate, or a derivative thereof having anoligo-benzamide compound and one or more pharmaceutically acceptablecarriers. The oligo-benzamide compound includes two or three optionallysubstituted benzamides (e.g., substituted and/or non-substitutedbenzamides) and one substituent groups attached to each of thesubstituted benzamides individually by a chemical bond including ether,thioether, amine, amide, carbamate, urea, and carbon-carbon (single,double, and triple) bonds.

The use of the word “a” or “an” when used in conjunction with the term“comprising” in the claims and/or the specification may mean “one,” butit is also consistent with the meaning of “one or more,” “at least one,”and “one or more than one.”

The term “or combinations thereof” as used herein refers to allpermutations and combinations of the listed items preceding the term.For example, “A, B, C, or combinations thereof” is intended to includeat least one of: A, B, C, AB, AC, BC, or ABC, and if order is importantin a particular context, also BA, CA, CB, CBA, BCA, ACB, BAC, or CAB.The skilled artisan will understand that typically there is no limit onthe number of items or terms in any combination, unless otherwiseapparent from the context.

As used in this specification and claim(s), the words “comprising” (andany form of comprising, such as “comprise” and “comprises”), “having”(and any form of having, such as “have” and “has”), “including” (and anyform of including, such as “includes” and “include”) or “containing”(and any form of containing, such as “contains” and “contain”) areinclusive or open-ended and do not exclude additional, unrecitedelements or method steps.

These, and other, embodiments of the invention will be betterappreciated and understood when considered in conjunction with thefollowing description and the accompanying drawings. It should beunderstood, however, that the following description, while indicatingvarious embodiments of the invention and numerous specific detailsthereof, is given by way of illustration and not of limitation. Manysubstitutions, modifications, additions and/or rearrangements may bemade within the scope of the invention without departing from the spiritthereof, and the invention includes all such substitutions,modifications, additions and/or rearrangements. It is contemplated thatany method or composition described herein can be implemented withrespect to any other method or composition described herein.

BRIEF DESCRIPTION OF THE DRAWINGS

For a more complete understanding of the features and advantages of thepresent invention, reference is now made to the detailed description ofthe invention along with the accompanying figures and in which:

FIG. 1. Blocking AR PELP1 interaction should block AR-mediated genomicsignaling and may affect AR-mediated non-genomic signaling.

FIGS. 2A-2E. Modeling AR-PELP1 interactions. FIGS. 2A & 2B show thecrystal structures of wild-type AR ligand-binding domain with DHT as afront view (FIG. 2A) and as a ligand view (FIG. 2B). FIG. 2C shows thesequence of the AR domain noting the H3, H4, H5, and H12 regions (SEQ IDNOS: 4-5). Helices 3, 4, and 12 are highlighted which represent theactivation function 2 (AF2) region. The interaction is with the “nuclearreceptor box” or “LXXLL motif” (SEQ ID NO: 1). FIGS. 2D & 2E show thecrystal structure of the LXXLL (SEQ ID NO: 1) motif-bound AF-2 interfacefor human AR. The ball and stick model shows the key residues of one ofthe binding pockets around helices H3, H4, and H12. FIG. 2E shows thespace filling model of this binding pocket. The LXXLL (SEQ ID NO: 1)peptide has the sequence: SSRGLLWDLLTKDSR (SEQ ID NO: 2) with a K_(d) of1.8 μM. The flanking residues were highly disordered with 2 residues atN and 1 residue at C visible in the crystal structure. In the crystalstructure, Met734 causes displace of Leu (+1) away from H12 towards H3.The Lys720 interacts with the backbone and Glu897 interacts with thebackbone through a water molecule. Further information related to thesecrystal structures can be found in PLoS Biology, 2:e274, 2004.

FIG. 3. Structure of PELP1 schematically and at the amino acid sequence.

FIGS. 4A-F. (FIG. 4A) Chemical structure of the bis-benzamide (D2).(FIG. 4B) the lowest-energy conformation of D2. (FIG. 4C) the stereoviewof the superimposition of D2 on a helical turn. (FIG. 4D) the stereoviewof the superimposition of D2 on PELP1 LXXLL (SEQ ID NO: 1) motif and ahelical PELP1 LXXLL (SEQ ID NO: 1) motif; (FIG. 4E) stability of D2 inculture showing a single peak on the HPLC; (FIG. 4F) stability of D2over time upon incubation with cell lysates at 37° C. for days asspecified.

FIG. 5. Two isobutyl groups of the bis-benzamide D2 was designed tomimic the side chains of the two leucines at the i and i+4 positions ofthe LXXLL (SEQ ID NO: 1) motif, organizing hydrophobic surface for ARinteraction. On the other hand, a bis-benzamide containing two benzylgroups (D1) was synthesized as a control.

FIG. 6. Effect of D1 and D2 on DHT induced AR-PELP1co-immunoprecipitation in LNCaP cells.

FIGS. 7A-C. Effect of D1 and D2 on DHT induced AR-PELP1co-immunoprecipitation in LNCaP cells. (FIG. 7A) Model depicts theproposed role for D2 in disrupting the interaction between AR and NR Boxproteins such as Hsp27 and PELP1. (FIG. 7B) Effect of increasingconcentration of D2 on complex formation between AR and NR Box proteinssuch as Hsp27 and PELP1, as shown for immunoprecipitation with AR (toppanel) and with PELP1 (bottom panel). Input lysates are shown at thebottom. (FIG. 7C) Rescue of D2-induced suppression of AR-PELP1 complexformation: Following transient transfection with increasingconcentrations of AR (left panel) or increasing concentration of PELP1(right panel), LnCAP cells were treated with 10 nM DHT for 24 hoursfollowing preincubation with D2 or control D1. Extracts wereimmunoprecipitated with AR and immunoblotted with PELP1, AR or importin.

FIG. 8. Effect of D2 on DHT-induced transcription: RNA from LNCaP cellsuntreated or treated with DHT in the absence and presence of D2 wereevaluated by the Illumina platform for DHT-regulated transcripts. Theheat map shows the the basal level of expression in (light grey) andupregulated genes by DHT (dark grey). Expression levels of selectedgenes are shown in the right panel, including AR-regulated genes andthose involved in cell proliferation.

FIG. 9. D2 can block DHT-induced gene expression. The ability of D2 butnot D1 to block DHT-Induced gene expression was noted by transcriptionfrom a PSA-luciferase promoter (top left panel), from an ARE-luciferasereporter (top middle panel). D2 blocked AR binding to its cognate DNAsequence on the PSA promoter on CHIP assays (top right panel). Thiseffect of D2 could be rescued by overexpression of AR (bottom leftpanel) or PELP1 (bottom right panel).

FIGS. 10A-E. D2 blocks proliferation of prostate cancer cells in vitroand in vivo (a) Effect of pretreatment with 100 nM of D1 and D2 onDHT-induced proliferation in multiple prostate cancer cell lines in MTTassay. Numbers are normalized to a baseline of 100, which represents theuntreated rate of proliferation. (b) Effect of pretreatment with 100 nMof D1 and D2 on DHT-induced proliferation in LNCaPcells on a Cyquantassay. (c) Dose dependent curve of D2 on proliferation of LAPC4 cells.(d) Rescue of DHT induced proliferation by overexpression of PELP1following suppression of DHT induced proliferation with 100 nM of D2.(e). Effect of direct intratumoral injections of D1 and D2 on theproliferation of prostate cancer xenografts in animal models: Followingestablishment of subcutaneous xenografts in animal models, daily directintratumoral injections of D1 and D2 were performed. Bioluminesenceimaging was used to track the growth of the tumors and the effect of D1and D2 quantitated as shown in the graph. Evaluation of the proteinextracts from these tumors revealed that D2 was able to block AR-PELP1complex formation in the xenograft tumors.

FIG. 11. Specificity of D2 effect on proliferation: D2 does not affectEGF or LPA mediated proliferation of prostate cancer cells. D2 doesblock DHT-induced proliferation of prostate cancer cells.

FIG. 12. D2 does not block the non-genomic activation of erk by DHT.

FIGS. 13A-B. Effect on DHT-induced nuclear translocation of exogenousAR-GFP in LNCaP cells transiently transfected with AR. (a) Blue stain isDAPI (for nucleus) and green is AR (GFP). Baseline untreated LNCaP cellsare shown in top left panel. Cells were pretreated with DMSO (leftpanel), 100 nM D1 (middle panel) and 100 nM D2 (right panel) and thentreated with 1 nM DHT. AR nuclear translocation was visualized at 4hours following DHT treatment. (b) Nuclear and cytoplasmic extracts werecollected from similar cells and subject to western analyses.

FIGS. 14A-C. Effect of chemical conjugation of Fluorescein to D2 at theamino and carboxy terminus (FIG. 14A) on uptake by LnCaP cells at 4hours (FIG. 14B) and on DHT-induced proliferation of PCa cells (FIG.14C).

FIG. 15. CF2D2 can get into the cell. Evidence obtained by confocalmicroscopy reveals that CF2D2 can widely get into the cell upontreatment. Background autofluorescene in C4-2 cells is minimal asevidenced by the no treatment group.

FIG. 16. Evidence for utility of higher concentrations of D1 in blockingerk phosphorylation: following serum starvation, cells were treated witheither D1 or D2 and assessed for their ability to block erkphosphorylation. D1 blocks erk phosphorylation.

FIG. 17. evaluation of the utility of peptidomimetics on DHT inducedproliferation of prostate cancer cells. The more effective the compound,the lower the concentration at which it affects the proliferation ofprostate cancer cells. An ideal compound (***) is denoted with threeblack stars and has the highest efficacy at the lowest concentration andis shown for compounds below. For each of the derivatives in FIGS.19A-N, this graph represents the effectiveness of each compound.

FIG. 18. Modifications of the D2 peptidomimetics.

FIGS. 19A-N. Structure-function relationship of peptidomimeticanalogues.

FIG. 20. Highest activity compounds.

FIG. 21. Evaluation of the utility of peptidomimetics on DHT inducedtranscription from an ARE-luciferase in prostate cancer cells.

FIG. 22. Evaluation of the utility of peptidomimetics on DHT inducedAR-PELP1 complex formation in a co-immunoprecipiration assay in prostatecancer cells.

DETAILED DESCRIPTION OF THE INVENTION

As discussed above, the interaction between PELP-1 and AR is believed toplay a role in carcinogenesis. Since PELP-1 is thought to bind AR viaits LXXLL (SEQ ID NO: 1) motif, the inventors sought to developbis-benzamide-based peptidomimetics by a rational design approach inorder to competitively disrupt AR and PELP-1 interaction.

The bis-benzamide contains two alkyl groups (R₁₋₂) that correspond tothe i and i+4 positions of a helix. The bis-benzamide designated D2 hastwo isobutyl groups and emulates the side chain groups of two leucinesat the i and i+4 positions of the LXXLL (SEQ ID NO: 1) motif andpresents leucines spaced a helical turn apart. Prior attempts to targetthe LXXLL (SEQ ID NO: 1) motif with peptides and peptidomimetics havenot been successful as the spacing between the leucines has not beenoptimal for functional activity in vivo.

The peptidomimetics of the present invention are non-toxic under invitro and in vivo conditions. The development of these peptidomimeticsrepresents a quantum leap in the development of a drug to target ARsignaling. Interestingly, these synthetic molecules preventandrogen-induced translocation of AR to the nucleus and representsperhaps one of the first instances of peptidomimetic agents that blockAR nuclear translocation. In addition to improvements in the helicalface and presentation of the leucines, the inventors have provenefficacy of this system against prostate cancer cell proliferation bothin vitro and in vivo. Thus, in contrast to existing technology, theinventors have developed and tested an active peptidomimetic againstprostate cancer and other androgen receptor involved cancers.

A particular peptidomimetic, D2, is non-toxic to prostate cancer cells,enters the prostate cancer cells and selectively targets androgenreceptor signaling via the genomic pathway. They have shown that thissynthetic peptidomimetic D2 is capable of blocking AR-PELP-1interaction, nuclear translocation of AR, AR mediated genomic signalingas well as DHT-mediated proliferation of prostate cancer cells in vitro.The IC₅₀ of D2 appears to be around 40 nM. The effect of the D2peptidomimetic appears to be specific to blocking AR-PELP-1 interaction,as overexpression of AR or PELP-1 may overcome D2-mediated blockade.Finally, the inventors have shown that intratumoral or intraperitonealadministration of D2 can significantly abrogate the growth of prostatecancer cells implanted subcutaneously into nude mice. In comparison,administration of either control peptidomimetics or control soluent hasno effect on the growth of prostate cancer cells in vitro or in vivo. Inaddition, the inventors have generated and tested hundreds of variantsof D2 and have identified related peptidomimetics with similar orequivalent potency.

These findings are exciting and represent a potentially viable method totarget AR signaling pathways in prostate cancer. These peptidomimeticshave advantages of both peptides (e.g., high efficacy and selectivity,low side effects) and small organic molecules (e.g., high enzymestability, oral bioavailability, effective cell permeability). Inaddition, the novel platform using the peptidomimetics with a rigidoligo-benzamide backbone allows the presentation of selected amino acidside chains in the proper helical structure that is critical for optimalAR interactions.

I. Definitions

To facilitate the understanding of this invention, a number of terms aredefined below. Terms defined herein have meanings as commonly understoodby a person of ordinary skill in the areas relevant to the presentinvention. Terms such as “a”, “an” and “the” are not intended to referto only a singular entity, but include the general class of which aspecific example may be used for illustration. The terminology herein isused to describe specific embodiments of the invention, but their usagedoes not delimit the invention, except as outlined in the claims.

As used herein, the term “alkyl” denotes branched or unbranchedhydrocarbon chains, having between about 1-20 carbons, with “loweralkyl” denoting branched or unbranched hydrocarbon chains, havingbetween about 1-10 carbons. Non-limiting examples include methyl, ethyl,propyl, n-propyl, isopropyl, butyl, n-butyl, sec-butyl, isobutyl,t-butyl, 1-methylpropyl, pentyl, isopentyl, sec-pentyl, 2-methylpentyl,hexyl, heptyl, octyl, nonyl, decyl, octadecyl and so on. Alkyl includescycloalkyl, such as cyclopropyl, cyclobutyl, cyclopentyl, andcyclohexyl. If not otherwise specified, these groups can be optionallysubstituted with one or more functional groups which are attachedcommonly to such chains, such as, hydroxyl, bromo, fluoro, chloro, iodo,mercapto or thio, cyano, alkylthio, heterocyclyl, aryl, heteroaryl,carboxyl, carbalkoyl, carboxamidyl, alkoxycarbonyl, carbamoyl, alkyl,alkenyl, alkynyl, nitro, amino, alkoxy, amido, imino, imido, guanidino,hydrazido, aminoxy, alkoxyamino, and the like to form alkyl groups suchas trifluoro methyl, 3-hydroxyhexyl, 2-carboxypropyl, 2-fluoroethyl,carboxymethyl, cyanobutyl and the like.

As used herein, the term “aryl” denotes a chain of carbon atoms whichform at least one aromatic ring having between about 4-20 carbon atoms,such as phenyl, naphthyl, biphenyl, anthracenyl, pyrenyl,tetrahydronaphthyl, and so on, any of which may be optionallysubstituted. Aryl also includes arylalkyl groups such as benzyl,phenethyl, and phenylpropyl. Aryl includes a ring system containing anoptionally substituted 5 or 6-membered carbocyclic aromatic ring, saidsystem may be bicyclic, polycyclic, bridge, and/or fused. The system mayinclude rings that are aromatic, or partially or completely saturated.Examples of ring systems include phenyl, naphtyl, biphenyl, anthracenyl,pyrenyl, imidazolyl, triazolyl, tetraazolyl, oxazolyl, thiophenyl,pyridyl, pyrrolyl, furanyl, quinolyl, quinolinyl, indenyl, pentalenyl,1,4-dihydronaphthyl, indanyl, benzimidazolyl, benzothiophenyl, indolyl,benzofuranyl, isoquinolinyl, and so on. If not otherwise specified, thegroup may be substituted with one or more functional groups which areattached commonly to such chains, such as hydroxyl, bromo, fluoro,chloro, iodo, mercapto or thio, cyano, cyanoamido, alkylthio,heterocycle, aryl, heteroaryl, carboxyl, carbalkoyl, carboxamidyl,alkoxycarbonyl, carbamyl, alkyl, alkenyl, alkynyl, nitro, amino, alkoxy,amido, imino, imido, guanidino, hydrazido, aminoxy, alkoxyamino and thelike to form aryl groups such as biphenyl, iodobiphenyl,methoxybiphenyl, anthryl, bromophenyl, iodophenyl, chlorophenyl,hydroxyphenyl, methoxyphenyl, formylphenyl, acetylphenyl,trifluoromethylthiophenyl, trifluoromethoxyphenyl, alkylthiophenyl,trialkylammoniumphenyl, aminophenyl, amidophenyl, thiazolylphenyl,oxazolylphenyl, imidazolylphenyl, imidazolylmethylphenyl, and the like.

As used herein, the term “alkenyl” includes optionally substitutedstraight chain and branched hydrocarbons having between about 1-50carbons as above with at least one carbon-carbon double bond (sp²).Alkenyls include ethenyl (or vinyl), prop-1-enyl, prop-2-enyl (orallyl), isopropenyl (or 1-methylvinyl), but-1-enyl, but-2-enyl,butadienyls, pentenyls, hexa-2,4-dienyl, and so on. Hydrocarbons havinga mixture of double bonds and triple bonds, such as 2-penten-4-ynyl, aregrouped as alkynyls herein. Alkenyl includes cycloalkenyl. Cis and transor (E) and (Z) forms are included within the invention. If not otherwisespecified, these groups can be optionally substituted with one or morefunctional groups which are attached commonly to such chains, such as,hydroxyl, bromo, fluoro, chloro, iodo, mercapto or thio, cyano,alkylthio, heterocyclyl, aryl, heteroaryl, carboxyl, carbalkoyl,carboxamidyl, alkoxycarbonyl, carbamoyl, alkyl, alkenyl, alkynyl, nitro,amino, alkoxy, amido, imino, imido, guanidino, hydrazido, aminoxy,alkoxyamino and the like to form alkyl groups such as trifluoro methyl,3-hydroxyhexyl, 2-carboxypropyl, 2-fluoroethyl, carboxymethyl,cyanobutyl and the like.

As used herein, the term “alkynyl” includes optionally substitutedstraight chain and branched hydrocarbons having between about 1-50carbons as above with at least one carbon-carbon triple bond (sp).Alkynyls include ethynyl, propynyls, butynyls, and pentynyls.Hydrocarbons having a mixture of double bonds and triple bonds, such as2-penten-4-ynyl, are grouped as alkynyls herein. Alkynyl does notinclude cycloalkynyl. If not otherwise specified, these groups can beoptionally substituted with one or more functional groups which areattached commonly to such chains, such as, hydroxyl, bromo, fluoro,chloro, iodo, mercapto or thio, cyano, alkylthio, heterocyclyl, aryl,heteroaryl, carboxyl, carbalkoyl, carboxamidyl, alkoxycarbonyl,carbamoyl, alkyl, alkenyl, alkynyl, nitro, amino, alkoxy, amido, imino,imido, guanidino, hydrazido, aminoxy, alkoxyamino and the like to formalkyl groups such as trifluoro methyl, 3-hydroxyhexyl, 2-carboxypropyl,2-fluoroethyl, carboxymethyl, cyanobutyl and the like.

As used herein, the term “alkoxy” includes an optionally substitutedstraight chain or branched alkyl group having between about 1-50 carbonswith a terminal oxygen linking the alkyl group to the rest of themolecule. Alkoxy includes methoxy, ethoxy, propoxy, isopropoxy, butoxy,t-butoxy, pentoxy and so on. If not otherwise specified, alkyoxy alsoincludes any substituted alkyl group connected by an ether linkage, suchas aminobutoxy, carboxyethoxy, hydroxyethoxy and so on. “Aminoalkyl”,“thioalkyl”, and “sulfonylalkyl” are analogous to alkoxy, replacing theterminal oxygen atom of alkoxy with, respectively, NH (or NR), S, andSO₂. Heteroalkyl includes alkoxy, aminoalkyl, thioalkyl, and so on.

For any of the groups above, the modifier Cn-Cn′ defines both theminimum and maximum number of carbon atoms for the group. For example,“C₂-C₁₀ alkyl” designates those alkyl groups having from 2 to 10 carbonatoms (e.g., 2, 3, 4, 5, 6, 7, 8, 9, or 10, or any range derivabletherein, e.g., 3 to 10 carbon atoms).

As used herein, the term “pharmaceutically acceptable” means that whichis useful in preparing a pharmaceutical composition that is generallysafe, non-toxic and neither biologically nor otherwise undesirable andincludes that which is acceptable for veterinary use as well as humanpharmaceutical use.

As used herein, the term “pharmaceutically acceptable salts” means saltsof compounds of the present invention which are pharmaceuticallyacceptable, as defined above, and which possess the desiredpharmacological activity. Such salts include acid addition salts formedwith inorganic acids such as hydrochloric acid, hydrobromic acid,sulfuric acid, nitric acid, phosphoric acid, and the like; or withorganic acids such as acetic acid, propionic acid, hexanoic acid,heptanoic acid, cyclopentanepropionic acid, glycolic acid, pyruvic acid,lactic acid, malonic acid, succinic acid, malic acid, maleic acid,fumaric acid, tartaric acid, citric acid, benzoic acid,o-(4-hydroxybenzoyl)benzoic acid, cinnamic acid, mandelic acid,methanesulfonic acid, ethanesulfonic acid, 1,2-ethanedisulfonic acid,2-hydroxyethanesulfonic acid, benzenesulfonic acid,p-chlorobenzenesulfonic acid, 2-naphthalenesulfonic acid,p-toluenesulfonic acid, camphorsulfonic acid,4-methylbicyclo[2.2.2]oct-2-ene-1-carboxylic acid, glucoheptonic acid,4,4′-methylenebis(3-hydroxy-2-ene-1-carboxylic acid), 3-phenylpropionicacid, trimethylacetic acid, tertiary butylacetic acid, lauryl sulfuricacid, gluconic acid, glutamic acid, hydroxynaphthoic acid, salicylicacid, stearic acid, muconic acid and the like.

Pharmaceutically acceptable salts also include base addition salts,which may be formed when acidic protons present are capable of reactingwith inorganic or organic bases. Acceptable inorganic bases includesodium hydroxide, sodium carbonate, potassium hydroxide, aluminumhydroxide and calcium hydroxide. Acceptable organic bases includeethanolamine, diethanolamine, triethanolamine, tromethamine,N-methylglucamine and the like.

II. Oligo-Benzamides and Methods of Synthesis

The present invention provides synthetic molecules which present theessential functionalities of corresponding peptide ligands in the properthree dimensional orientation that enables specific proteininteractions, leading to either stimulation or inhibition ofprotein-mediated functions.

Peptidomimetics (also known as peptide mimetics) are small organiccompounds which lack the peptide backbone of native peptides. Despitethis modification, they still retain an ability to interact withcorresponding receptors or enzymes by presenting essential chemicalfunctionalities (i.e., pharmacophores) in characteristicthree-dimensional patterns which are complimentary to the targetproteins (Marshall, 1993; Ahn et al., 2002). Thereby, peptidomimeticspotentially combine the advantages of peptides (e.g., high efficacy andselectivity, low side effects) and small organic molecules (e.g., highenzymatic stability and oral bioavailability).

To mimic α-helices, the present invention provides an oligo-benzamidescaffold that is rigid in structure and place and orient substituents asan α-helix does. Substitution on the rigid tris-benzamide, for instance,allowed easy placement of three functional groups (R₁₋₃) correspondingto the side chains of amino acids found at the i, i+4, and i+7 positionsof an ideal α-helix. Furthermore, the present inventors have developed afacile synthetic route to prepare a number of tris-benzamides torepresent α-helical segments of target proteins. U.S. Patent Publication2009/0012141, incorporated herein by reference, discloses a variety ofoligo-benzamide compounds and methods of synthesis therefor.

More specifically, the present invention provides an oligo-benzamidepeptidomimetic compound as illustrated includes 2 or 3 optionallysubstituted benzamides—so called “bis” and “tris” benzamides. Inaddition, linkages between the optionally substituted benzamides may bevaried as necessary including ester, thioester, thioamide,trans-ethylene, ethyl, methyloxy, methylamino, hydroxyethyl, carbamate,urea, imide, hydrozido, aminoxy, or other linkages known to the skilledartisan. And, the oligo-benzamide peptidomimetic compound may beattached to amino acids, oligopeptides, optionally substituted alkyl, orother structures known to the skilled artisan.

The substitution on the substituted benzamide is generally on a benzenering and may be on the 2, 3, 4, 5, or 6 position of each of the benzenerings. The substitutions may be at the same position on each of thebenzamide rings but may also be at different positions on each of thebenzene rings. For example, the substitution is connected to thebenzamide ring by a chemical linkage including ether, thioether, amine,amide, carbamate, urea, and carbon-carbon (single-, double-, andtriple-) bonds, and the substitution comprises optionally substitutedalkyl groups, lower alkyl groups, alkoxy groups, alkoxyalkyl groups,hydroxy groups, hydroxyalkyl groups, alkenyl groups, amino groups, iminogroups, nitrate groups, alkylamino groups, nitroso groups, aryl groups,biaryl groups, bridged aryl groups, fused aryl groups, alkylaryl groups,arylalkyl groups, arylalkoxy groups, arylalkylamino groups, cycloalkylgroups, bridged cycloalkyl groups, cycloalkoxy groups, cycloalkyl-alkylgroups, arylthio groups, alkylthio groups, alkylsulfinyl groups,alkylsulfonyl groups, arylsulfonyl groups, arylsulfinyl groups,caboxamido groups, carbamoyl groups, carboxyl groups, carbonyl groups,alkoxycarbonyl groups, halogen groups, haloalkyl groups, haloalkoxygroups, heteroayl, heterocyclic ring, arylheterocyclic ring,heterocyclic compounds, amido, imido, guanidino, hydrazido, aminoxy,alkoxyamino, alkylamido, carboxylic ester groups, thioethers groups,carboxylic acids, phosphoryl groups or combination thereof.

The present invention also provides an oligo-benzamide peptidomimeticcompound that includes at least two optionally substituted benzamides,with each of the substituted benzamides having one substitution on abenzene ring. The substitutions are individually attached to the benzenerings of the oligo-benzamide peptidomimetic compound by a chemicallinkage including ether, thioether, amine, amide, carbamate, urea, andcarbon-carbon (single-, double-, and triple-) bonds. The substitutionsgenerally include optionally substituted alkyl groups, lower alkylgroups, alkoxy groups, alkoxyalkyl groups, hydroxy groups, hydroxyalkylgroups, alkenyl groups, amino groups, imino groups, nitrate groups,alkylamino groups, nitroso groups, aryl groups, biaryl groups, bridgedaryl groups, fused aryl groups, alkylaryl groups, arylalkyl groups,arylalkoxy groups, arylalkylamino groups, cycloalkyl groups, bridgedcycloalkyl groups, cycloalkoxy groups, cycloalkyl-alkyl groups, arylthiogroups, alkylthio groups, alkylsulfinyl groups, alkylsulfonyl groups,aryl sulfonyl groups, arylsulfinyl groups, cab oxami do groups,carbamoyl groups, carboxyl groups, carbonyl groups, alkoxycarbonylgroups, halogen groups, haloalkyl groups, haloalkoxy groups, heteroayl,heterocyclic ring, arylheterocyclic ring, heterocyclic compounds, amido,imido, guanidino, hydrazido, aminoxy, alkoxyamino, alkylamido,carboxylic ester groups, thioethers groups, carboxylic acids, phosphorylgroups or combination thereof.

U.S. Patent Publication 2009/0012141 provides synthesis schemes toprepare α-helix mimetic compounds of the present invention, for example,in FIG. 2 therein. A specific example in that document provides fifteenα-helix mimetic compounds made starting with a 4-amino-3-hydroxybenzoicacid compound 7, which was converted to an N—Ac protected methyl estercompound 8. Various alkyl groups were introduced to the hydroxyl groupusing a variety of alkyl halides and a base (e.g., NaOH) known to theskilled artisan. After the alkylation reaction, the methyl estercompound 9 was hydrolyzed using a base (like LiOH), and methyl4-amino-3-hydroxybenzoate compound 10 was coupled to the free benzoicacid using a coupling reagent (like BOP), resulting in a benzamidecompound 11 containing one alkyl group corresponding to the i positionof a helix. These steps were repeated to synthesize oligo-benzamidecompounds. Those of skill in the art would understand the broaderapplicability of such methods in the synthesis of other compounds suchas those disclosed herein.

II. Pharmaceutical Formulations and Methods of Treatment

A. Formulations

The active compositions of the present invention may include classicpharmaceutical preparations. Administration of these compositionsaccording to the present invention will be via any common route so longas the target tissue is available via that route. This includes oral,nasal, buccal, rectal, vaginal or topical. Alternatively, administrationmay be by intradermal, subcutaneous, intramuscular, intraperitoneal orintravenous injection. Such compositions would normally be administeredas pharmaceutically acceptable compositions, described supra. Ofparticular interest is direct intratumoral administration, perfusion ofa tumor, or administration local or regional to a tumor, for example, inthe local or regional vasculature or lymphatic system, or in a resectedtumor bed (e.g., post-operative catheter). For practically any tumor,systemic delivery also is contemplated. This will prove especiallyimportant for attacking microscopic or metastatic cancer.

The active compounds may also be administered as free base orpharmacologically acceptable salts can be prepared in water suitablymixed with a surfactant, such as hydroxypropylcellulose. Dispersions canalso be prepared in glycerol, liquid polyethylene glycols, and mixturesthereof and in oils. Under ordinary conditions of storage and use, thesepreparations contain a preservative to prevent the growth ofmicroorganisms.

The pharmaceutical forms suitable for injectable use include sterileaqueous solutions or dispersions and sterile powders for theextemporaneous preparation of sterile injectable solutions ordispersions. In all cases the form must be sterile and must be fluid tothe extent that easy syringability exists. It must be stable under theconditions of manufacture and storage and must be preserved against thecontaminating action of microorganisms, such as bacteria and fungi. Thecarrier can be a solvent or dispersion medium containing, for example,water, ethanol, polyol (for example, glycerol, propylene glycol, andliquid polyethylene glycol, and the like), suitable mixtures thereof,and vegetable oils. The proper fluidity can be maintained, for example,by the use of a coating, such as lecithin, by the maintenance of therequired particle size in the case of dispersion and by the use ofsurfactants. The prevention of the action of microorganisms can bebrought about by various antibacterial an antifungal agents, forexample, parabens, chlorobutanol, phenol, sorbic acid, thimerosal, andthe like. In many cases, it will be preferable to include isotonicagents, for example, sugars or sodium chloride. Prolonged absorption ofthe injectable compositions can be brought about by the use in thecompositions of agents delaying absorption, for example, aluminummonostearate and gelatin.

Sterile injectable solutions are prepared by incorporating the activecompounds in the required amount in the appropriate solvent with variousof the other ingredients enumerated above, as required, followed byfiltered sterilization. Generally, dispersions are prepared byincorporating the various sterilized active ingredients into a sterilevehicle which contains the basic dispersion medium and the requiredother ingredients from those enumerated above. In the case of sterilepowders for the preparation of sterile injectable solutions, thepreferred methods of preparation are vacuum-drying and freeze-dryingtechniques which yield a powder of the active ingredient plus anyadditional desired ingredient from a previously sterile-filteredsolution thereof.

As used herein, “pharmaceutically acceptable carrier” includes any andall solvents, dispersion media, coatings, antibacterial and antifungalagents, isotonic and absorption delaying agents and the like. The use ofsuch media and agents for pharmaceutical active substances is well knownin the art. Except insofar as any conventional media or agent isincompatible with the active ingredient, its use in the therapeuticcompositions is contemplated. Supplementary active ingredients can alsobe incorporated into the compositions.

The compositions of the present invention may be formulated in a neutralor salt form. Pharmaceutically-acceptable salts include the acidaddition salts (formed with the free amino groups of the protein) andwhich are formed with inorganic acids such as, for example, hydrochloricor phosphoric acids, or such organic acids as acetic, oxalic, tartaric,mandelic, and the like. Salts formed with the free carboxyl groups canalso be derived from inorganic bases such as, for example, sodium,potassium, ammonium, calcium, or ferric hydroxides, and such organicbases as isopropylamine, trimethylamine, histidine, procaine and thelike.

Upon formulation, solutions will be administered in a manner compatiblewith the dosage formulation and in such amount as is therapeuticallyeffective. The actual dosage amount of a composition of the presentinvention administered to a patient or subject can be determined byphysical and physiological factors such as body weight, severity ofcondition, the type of disease being treated, previous or concurrenttherapeutic interventions, idiopathy of the patient and on the route ofadministration. The practitioner responsible for administration will, inany event, determine the concentration of active ingredient(s) in acomposition and appropriate dose(s) for the individual subject.

The pharmaceutical peptidomimetic composition includes a therapeuticallyeffective amount of an oligo-benzamide peptidomimetic compound or asalt, a solvent, or a derivative thereof based on an oligo-benzamidepeptidomimetic compound, and one or more pharmaceutically acceptablecarriers. For example, the bis- or tris-benzamide peptidomimeticcomposition may also include one or more additional active ingredients,diluents, excipients, active agents, lubricants, preservatives,stabilizers, wetting agents, emulsifiers, salts for influencing osmoticpressure, buffers, colorings, flavorings, aromatic substances,penetration enhancers, surfactants, fatty acids, bile salts, chelatingagents, colloids and combinations thereof. The pharmaceuticalpeptidomimetic compound may be adapted for oral, dermatological,transdermal or parenteral administration, in the form of a solution, aemulsions, a liposome-containing formulation, a tablet, a capsule, a gelcapsule, a liquid syrup, a soft gel, a suppository, an enema, a patch,an ointment, a lotion, a cream, a gel, a drop, a spray, a liquid or apowder.

B. Prostate Cancer

Prostate cancer is a disease in which cancer develops in the prostate, agland in the male reproductive system. In 2007, almost 220,000 new caseswere reported, and over 27,000 deaths were attributed to thismalignancy. It occurs when cells of the prostate mutate and begin tomultiply out of control. These cells may spread (metastasize) from theprostate to other parts of the body, especially the bones and lymphnodes. Prostate cancer may cause pain, difficulty in urinating, erectiledysfunction and other symptoms.

Rates of prostate cancer vary widely across the world. Although therates vary widely between countries, it is least common in South andEast Asia, more common in Europe, and most common in the United States.According to the American Cancer Society, prostate cancer is leastcommon among Asian men and most common among black men, with figures forwhite men in-between. However, these high rates may be affected byincreasing rates of detection.

Prostate cancer develops most frequently in men over fifty. This cancercan occur only in men, as the prostate is exclusively of the malereproductive tract. It is the most common type of cancer in men in theUnited States, where it is responsible for more male deaths than anyother cancer, except lung cancer. However, many men who develop prostatecancer never have symptoms, undergo no therapy, and eventually die ofother causes. Many factors, including genetics and diet, have beenimplicated in the development of prostate cancer.

Prostate cancer screening is an attempt to find unsuspected cancers.Screening tests may lead to more specific follow-up tests such as abiopsy, where small pieces of the prostate are removed for closer study.As of 2006 prostate cancer screening options include the digital rectalexam and the prostate specific antigen (PSA) blood test. Screening forprostate cancer is controversial because it is not clear if the benefitsof screening outweigh the risks of follow-up diagnostic tests and cancertreatments.

Prostate cancer is a slow-growing cancer, very common among older men.In fact, most prostate cancers never grow to the point where they causesymptoms, and most men with prostate cancer die of other causes beforeprostate cancer has an impact on their lives. The PSA screening test maydetect these small cancers that would never become life threatening.Doing the PSA test in these men may lead to overdiagnosis, includingadditional testing and treatment. Follow-up tests, such as prostatebiopsy, may cause pain, bleeding and infection. Prostate cancertreatments may cause urinary incontinence and erectile dysfunction.Therefore, it is essential that the risks and benefits of diagnosticprocedures and treatment be carefully considered before PSA screening.

Prostate cancer screening generally begins after age 50, but this canvary due to ethnic backgrounds. Thus, the American Academy of FamilyPhysicians and American College of Physicians recommend the physiciandiscuss the risks and benefits of screening and decide based onindividual patient preference. Although there is no officiallyrecommended cutoff, many health care providers stop monitoring PSA inmen who are older than 75 years old because of concern that prostatecancer therapy may do more harm than good as age progresses and lifeexpectancy decreases.

Digital rectal examination (DRE) is a procedure where the examinerinserts a gloved, lubricated finger into the rectum to check the size,shape, and texture of the prostate. Areas which are irregular, hard orlumpy need further evaluation, since they may contain cancer. Althoughthe DRE only evaluates the back of the prostate, 85% of prostate cancersarise in this part of the prostate. Prostate cancer which can be felt onDRE is generally more advanced. The use of DRE has never been shown toprevent prostate cancer deaths when used as the only screening test.

The PSA test measures the blood level of prostate-specific antigen, anenzyme produced by the prostate. Specifically, PSA is a serine proteasesimilar to kallikrein. Its normal function is to liquify gelatinoussemen after ejaculation, allowing spermatazoa to more easily navigatethrough the uterine cervix.

PSA levels under 4 ng/mL (nanograms per milliliter) are generallyconsidered normal, however in individuals below the age of 50 sometimesa cutoff of 2.5 is used for the upper limit of normal, while levels over4 ng/mL are considered abnormal (although in men over 65 levels up to6.5 ng/mL may be acceptable, depending upon each laboratory's referenceranges). PSA levels between 4 and 10 ng/mL indicate a risk of prostatecancer higher than normal, but the risk does not seem to rise withinthis six-point range. When the PSA level is above 10 ng/mL, theassociation with cancer becomes stronger. However, PSA is not a perfecttest. Some men with prostate cancer do not have an elevated PSA, andmost men with an elevated PSA do not have prostate cancer.

PSA levels can change for many reasons other than cancer. Two commoncauses of high PSA levels are enlargement of the prostate (benignprostatic hypertrophy (BPH)) and infection in the prostate(prostatitis). It can also be raised for 24 hours after ejaculation andseveral days after catheterization. PSA levels are lowered in men whouse medications used to treat BPH or baldness. These medications,finasteride (marketed as Proscar or Propecia) and dutasteride (marketedas Avodart), may decrease the PSA levels by 50% or more.

Several other ways of evaluating the PSA have been developed to avoidthe shortcomings of simple PSA screening. The use of age-specificreference ranges improves the sensitivity and specificity of the test.The rate of rise of the PSA over time, called the PSA velocity, has beenused to evaluate men with PSA levels between 4 and 10 ng/ml, but as of2006, it has not proven to be an effective screening test. Comparing thePSA level with the size of the prostate, as measured by ultrasound ormagnetic resonance imaging, has also been studied. This comparison,called PSA density, is both costly and, as of 2006, has not proven to bean effective screening test. PSA in the blood may either be free orbound to other proteins. Measuring the amount of PSA which is free orbound may provide additional screening information, but as of 2006,questions regarding the usefulness of these measurements limit theirwidespread use.

When a man has symptoms of prostate cancer, or a screening testindicates an increased risk for cancer, more invasive evaluation isoffered. The only test which can fully confirm the diagnosis of prostatecancer is a biopsy, the removal of small pieces of the prostate formicroscopic examination. However, prior to a biopsy, several other toolsmay be used to gather more information about the prostate and theurinary tract. Cystoscopy shows the urinary tract from inside thebladder, using a thin, flexible camera tube inserted down the urethra.Transrectal ultrasonography creates a picture of the prostate usingsound waves from a probe in the rectum.

If cancer is suspected, a biopsy is offered. During a biopsy a urologistobtains tissue samples from the prostate via the rectum. A biopsy guninserts and removes special hollow-core needles (usually three to six oneach side of the prostate) in less than a second. Prostate biopsies areroutinely done on an outpatient basis and rarely requirehospitalization. Fifty-five percent of men report discomfort duringprostate biopsy.

The tissue samples are then examined under a microscope to determinewhether cancer cells are present, and to evaluate the microscopicfeatures of any cancer found. If cancer is present, the pathologistreports the grade of the tumor. The grade tells how much the tumortissue differs from normal prostate tissue and suggests how fast thetumor is likely to grow. The Gleason system is used to grade prostatetumors from 2 to 10, where a Gleason score of 10 indicates the mostabnormalities. The pathologist assigns a number from 1 to 5 for the mostcommon pattern observed under the microscope, then does the same for thesecond most common pattern. The sum of these two numbers is the Gleasonscore. The Whitmore-Jewett stage is another method sometimes used.Proper grading of the tumor is critical, since the grade of the tumor isone of the major factors used to determine the treatment recommendation.

An important part of evaluating prostate cancer is determining thestage, or how far the cancer has spread. Knowing the stage helps defineprognosis and is useful when selecting therapies. The most common systemis the four-stage TNM system (abbreviated from Tumor/Nodes/Metastases).Its components include the size of the tumor, the number of involvedlymph nodes, and the presence of any other metastases.

The most important distinction made by any staging system is whether ornot the cancer is still confined to the prostate. In the TNM system,clinical T1 and T2 cancers are found only in the prostate, while T3 andT4 cancers have spread elsewhere. Several tests can be used to look forevidence of spread. These include computed tomography to evaluate spreadwithin the pelvis, bone scans to look for spread to the bones, andendorectal coil magnetic resonance imaging to closely evaluate theprostatic capsule and the seminal vesicles. Bone scans should revealosteoblastic appearance due to increased bone density in the areas ofbone metastisis—opposite to what is found in many other cancers thatmetastisize.

Prostate cancer can be treated with surgery, radiation therapy, hormonaltherapy, occasionally chemotherapy, proton therapy, or some combinationof these. The age and underlying health of the man as well as the extentof spread, appearance under the microscope, and response of the cancerto initial treatment are important in determining the outcome of thedisease. Since prostate cancer is a disease of older men, many will dieof other causes before a slowly advancing prostate cancer can spread orcause symptoms. This makes treatment selection difficult. The decisionwhether or not to treat localized prostate cancer (a tumor that iscontained within the prostate) with curative intent is a patienttrade-off between the expected beneficial and harmful effects in termsof patient survival and quality of life.

Watchful waiting, also called “active surveillance,” refers toobservation and regular monitoring without invasive treatment. Watchfulwaiting is often used when an early stage, slow-growing prostate canceris found in an older man. Watchful waiting may also be suggested whenthe risks of surgery, radiation therapy, or hormonal therapy outweighthe possible benefits. Other treatments can be started if symptomsdevelop, or if there are signs that the cancer growth is accelerating(e.g., rapidly rising PSA, increase in Gleason score on repeat biopsy,etc.). Most men who choose watchful waiting for early stage tumorseventually have signs of tumor progression, and they may need to begintreatment within three years. Although men who choose watchful waitingavoid the risks of surgery and radiation, the risk of metastasis (spreadof the cancer) may be increased. For younger men, a trial of activesurveillance may not mean avoiding treatment altogether, but mayreasonably allow a delay of a few years or more, during which time thequality of life impact of active treatment can be avoided. Publisheddata to date suggest that carefully selected men will not miss a windowfor cure with this approach. Additional health problems that developwith advancing age during the observation period can also make it harderto undergo surgery and radiation therapy.

Clinically insignificant prostate tumors are often found by accidentwhen a doctor incorrectly orders a biopsy not following the recommendedguidelines (abnormal DRE and elevated PSA). The urologist must checkthat the PSA is not elevated for other reasons, prostatitis, etc. Anannual biopsy is often recommended by a urologist for a patient who hasselected watchful waiting when the tumor is clinically insignificant (noabnormal DRE or PSA). The tumors tiny size can be monitored this way andthe patient can decide to have surgery only if the tumor enlarges whichmay take many years or never.

Surgical removal of the prostate, or prostatectomy, is a commontreatment either for early stage prostate cancer, or for cancer whichhas failed to respond to radiation therapy. The most common type isradical retropubic prostatectomy, when the surgeon removes the prostatethrough an abdominal incision. Another type is radical perinealprostatectomy, when the surgeon removes the prostate through an incisionin the perineum, the skin between the scrotum and anus. Radicalprostatectomy can also be performed laparoscopically, through a seriesof small (1 cm) incisions in the abdomen, with or without the assistanceof a surgical robot.

Radical prostatectomy is effective for tumors which have not spreadbeyond the prostate; cure rates depend on risk factors such as PSA leveland Gleason grade. However, it may cause nerve damage that significantlyalters the quality of life of the prostate cancer survivor. The mostcommon serious complications are loss of urinary control and impotence.Reported rates of both complications vary widely depending on how theyare assessed, by whom, and how long after surgery, as well as thesetting (e.g., academic series vs. community-based or population-baseddata). Although penile sensation and the ability to achieve orgasmusually remain intact, erection and ejaculation are often impaired.Medications such as sildenafil (Viagra), tadalafil (Cialis), orvardenafil (Levitra) may restore some degree of potency. For most menwith organ-confined disease, a more limited “nerve-sparing” techniquemay help avoid urinary incontinence and impotence.

Radical prostatectomy has traditionally been used alone when the canceris small. In the event of positive margins or locally advanced diseasefound on pathology, adjuvant radiation therapy may offer improvedsurvival. Surgery may also be offered when a cancer is not responding toradiation therapy. However, because radiation therapy causes tissuechanges, prostatectomy after radiation has a higher risk ofcomplications.

Transurethral resection of the prostate, commonly called a “TURP,” is asurgical procedure performed when the tube from the bladder to the penis(urethra) is blocked by prostate enlargement. TURP is generally forbenign disease and is not meant as definitive treatment for prostatecancer. During a TURP, a small tube (cystoscope) is placed into thepenis and the blocking prostate is cut away.

In metastatic disease, where cancer has spread beyond the prostate,removal of the testicles (called orchiectomy) may be done to decreasetestosterone levels and control cancer growth.

Radiation therapy, also known as radiotherapy, uses ionizing radiationto kill prostate cancer cells. When absorbed in tissue, ionizingradiation such as y and x-rays damage the DNA in cells, which increasesthe probability of apoptosis. Two different kinds of radiation therapyare used in prostate cancer treatment: external beam radiation therapyand brachytherapy.

External beam radiation therapy uses a linear accelerator to producehigh-energy x-rays which are directed in a beam towards the prostate. Atechnique called Intensity Modulated Radiation Therapy (IMIRT) may beused to adjust the radiation beam to conform with the shape of thetumor, allowing higher doses to be given to the prostate and seminalvesicles with less damage to the bladder and rectum. External beamradiation therapy is generally given over several weeks, with dailyvisits to a radiation therapy center. New types of radiation therapy mayhave fewer side effects then traditional treatment, one of these isTomotherapy.

Permanent implant brachytherapy is a popular treatment choice forpatients with low to intermediate risk features, can be performed on anoutpatient basis, and is associated with good 10-year outcomes withrelatively low morbidity. It involves the placement of about 100 small“seeds” containing radioactive material (such as iodine¹²⁵ orpalladium¹⁰³) with a needle through the skin of the perineum directlyinto the tumor while under spinal or general anesthetic. These seedsemit lower-energy X-rays which are only able to travel a short distance.Although the seeds eventually become inert, they remain in the prostatepermanently. The risk of exposure to others from men with implantedseeds is generally accepted to be insignificant.

Radiation therapy is commonly used in prostate cancer treatment. It maybe used instead of surgery for early cancers, and it may also be used inadvanced stages of prostate cancer to treat painful bone metastases.Radiation treatments also can be combined with hormonal therapy forintermediate risk disease, when radiation therapy alone is less likelyto cure the cancer. Some radiation oncologists combine external beamradiation and brachytherapy for intermediate to high risk situations.One study found that the combination of six months of androgensuppressive therapy combined with external beam radiation had improvedsurvival compared to radiation alone in patients with localized prostatecancer. Others use a “triple modality” combination of external beamradiation therapy, brachytherapy, and hormonal therapy.

Less common applications for radiotherapy are when cancer is compressingthe spinal cord, or sometimes after surgery, such as when cancer isfound in the seminal vesicles, in the lymph nodes, outside the prostatecapsule, or at the margins of the biopsy.

Radiation therapy is often offered to men whose medical problems makesurgery more risky. Radiation therapy appears to cure small tumors thatare confined to the prostate just about as well as surgery. However, asof 2006 some issues remain unresolved, such as whether radiation shouldbe given to the rest of the pelvis, how much the absorbed dose shouldbe, and whether hormonal therapy should be given at the same time.

Side effects of radiation therapy might occur after a few weeks intotreatment. Both types of radiation therapy may cause diarrhea and rectalbleeding due to radiation proctitis, as well as urinary incontinence andimpotence. Symptoms tend to improve over time. Men who have undergoneexternal beam radiation therapy will have a higher risk of laterdeveloping colon cancer and bladder cancer.

Cryosurgery is another method of treating prostate cancer. It is lessinvasive than radical prostatectomy, and general anesthesia is lesscommonly used. Under ultrasound guidance, metal rods are insertedthrough the skin of the perineum into the prostate. Highly purifiedArgon gas is used to cool the rods, freezing the surrounding tissue at−196° C. (−320° F.). As the water within the prostate cells freeze, thecells die. The urethra is protected from freezing by a catheter filledwith warm liquid. Cryosurgery generally causes fewer problems withurinary control than other treatments, but impotence occurs up to ninetypercent of the time. When used as the initial treatment for prostatecancer and in the hands of an experienced cryosurgeon, cryosurgery has a10 year biochemical disease free rate superior to all other treatmentsincluding radical prostatectomy and any form of radiation Cryosurgeryhas also been demonstrated to be superior to radical prostatectomy forrecurrent cancer following radiation therapy.

Hormonal therapy uses medications or surgery to block prostate cancercells from getting dihydrotestosterone (DHT), a hormone produced in theprostate and required for the growth and spread of most prostate cancercells. Blocking DHT often causes prostate cancer to stop growing andeven shrink. However, hormonal therapy rarely cures prostate cancerbecause cancers which initially respond to hormonal therapy typicallybecome resistant after one to two years. Hormonal therapy is thereforeusually used when cancer has spread from the prostate. It may also begiven to certain men undergoing radiation therapy or surgery to helpprevent return of their cancer.

Hormonal therapy for prostate cancer targets the pathways the body usesto produce DHT. A feedback loop involving the testicles, thehypothalamus, and the pituitary, adrenal, and prostate glands controlsthe blood levels of DHT. First, low blood levels of DHT stimulate thehypothalamus to produce gonadotropin releasing hormone (GnRH). GnRH thenstimulates the pituitary gland to produce luteinizing hormone (LH), andLH stimulates the testicles to produce testosterone. Finally,testosterone from the testicles and dehydroepiandrosterone from theadrenal glands stimulate the prostate to produce more DHT. Hormonaltherapy can decrease levels of DHT by interrupting this pathway at anypoint.

There are several forms of hormonal therapy. Orchiectomy is surgery toremove the testicles. Because the testicles make most of the body'stestosterone, after orchiectomy testosterone levels drop. Now theprostate not only lacks the testosterone stimulus to produce DHT, butalso it does not have enough testosterone to transform into DHT.

Anti-androgens are medications such as flutamide, bicalutamide,nilutamide, and cyproterone acetate which directly block the actions oftestosterone and DHT within prostate cancer cells.

Medications which block the production of adrenal androgens such as DHEAinclude ketoconazole and aminoglutethimide. Because the adrenal glandsonly make about 5% of the body's androgens, these medications aregenerally used only in combination with other methods that can block the95% of androgens made by the testicles. These combined methods arecalled total androgen blockade (TAB). TAB can also be achieved usingantiandrogens.

GnRH action can be interrupted in one of two ways. GnRH antagonistssuppress the production of LH directly, while GnRH agonists suppress LHthrough the process of downregulation after an initial stimulationeffect. Abarelix is an example of a GnRH antagonist, while the GnRHagonists include leuprolide, goserelin, triptorelin, and buserelin.Initially, GnRH agonists increase the production of LH. However, becausethe constant supply of the medication does not match the body's naturalproduction rhythm, production of both LH and GnRH decreases after a fewweeks.

As of 2006 the most successful hormonal treatments are orchiectomy andGnRH agonists. Despite their higher cost, GnRH agonists are often chosenover orchiectomy for cosmetic and emotional reasons. Eventually, totalandrogen blockade may prove to be better than orchiectomy or GnRHagonists used alone.

Each treatment has disadvantages which limit its use in certaincircumstances. Although orchiectomy is a low-risk surgery, thepsychological impact of removing the testicles can be significant. Theloss of testosterone also causes hot flashes, weight gain, loss oflibido, enlargement of the breasts (gynecomastia), impotence andosteoporosis. GnRH agonists eventually cause the same side effects asorchiectomy but may cause worse symptoms at the beginning of treatment.When GnRH agonists are first used, testosterone surges can lead toincreased bone pain from metastatic cancer, so antiandrogens or abarelixare often added to blunt these side effects. Estrogens are not commonlyused because they increase the risk for cardiovascular disease and bloodclots. The antiandrogens do not generally cause impotence and usuallycause less loss of bone and muscle mass. Ketoconazole can cause liverdamage with prolonged use, and aminoglutethimide can cause skin rashes.

Palliative care for advanced stage prostate cancer focuses on extendinglife and relieving the symptoms of metastatic disease. Chemotherapy maybe offered to slow disease progression and postpone symptoms. The mostcommonly used regimen combines the chemotherapeutic drug docetaxel witha corticosteroid such as prednisone. Bisphosphonates such as zoledronicacid have been shown to delay skeletal complications such as fracturesor the need for radiation therapy in patients with hormone-refractorymetastatic prostate cancer.

Bone pain due to metastatic disease is treated with opioid painrelievers such as morphine and oxycodone. External beam radiationtherapy directed at bone metastases may provide pain relief. Injectionsof certain radioisotopes, such as strontium⁸⁹, phosphorus³², orsamarium¹⁵³, also target bone metastases and may help relieve pain.

High Intensity Focused Ultrasound (HIFU) for prostate cancer utilizesultrasonnic waves to ablate/destroy the tissue of the prostate. Duringthe HIFU procedure, sound waves are used to heat the prostate tissuethus destroying the cancerous cells. Essentially, ultrasonic waves areprecisely focused on specific areas of the prostate to eliminate theprostate cancer with minimal risks of effecting other tissue or organs.Temperatures at the focal point of the sound waves can exceed 100° C.The ability to focus the ultrasonic waves leads to a relatively lowoccurrence of both incontinence and impotence. (0.6% and 0-20%,respectively). According to international studies, when compared toother procedures, HIFU has a high success rate with a reduced risk ofside effects. Studies using the Sonablate 500 HIFU machine have shownthat 94% of patients with a pretreatment PSA (Prostate Specific Antigen)of less than 10 g/ml were cancer-free after three years. However, manystudies of HIFU were performed by manufacturers of HIFU devices, ormembers of manufacturers' advisory panels.

HIFU was first used in the 1940's and 1950's in efforts to destroytumors in the central nervous system. Since then, HIFU has been shown tobe effective at destroying malignant tissue in the brain, prostate,spleen, liver, kidney, breast, and bone. Today, the HIFU procedure forprostate cancer is performed using a transrectal probe. This procedurehas been performed for over ten years and is currently approved for usein Japan, Europe, Canada, and parts of Central and South America.

Although not yet approved for use in the Unites States, many patientshave received the HIFU procedure at facilities in Canada, and Centraland South America. Currently, therapy is available using the Sonablate500 or the Ablatherm. The Sonablate 500 is designed by Focus Surgery ofIndianapolis, Ind. and is used in international HIFU centers around theworld.

Several medications and vitamins may also help prevent prostate cancer.Two dietary supplements, vitamin E and selenium, may help preventprostate cancer when taken daily. Estrogens from fermented soybeans andother plant sources (called phytoestrogens) may also help preventprostate cancer. The selective estrogen receptor modulator drugtoremifene has shown promise in early trials. Two medications whichblock the conversion of testosterone to dihydrotestosterone, finasterideand dutasteride, have also shown some promise. As of 2006 the use ofthese medications for primary prevention is still in the testing phase,and they are not widely used for this purpose. The problem with thesemedications is that they may preferentially block the development oflower-grade prostate tumors, leading to a relatively greater chance ofhigher grade cancers, and negating any overall survival improvement.Green tea may be protective (due to its polyphenol content), though thedata is mixed. A 2006 study of green tea derivatives demonstratedpromising prostate cancer prevention in patients at high risk for thedisease. In 2003, an Australian research team led by Graham Giles of TheCancer Council Australia concluded that frequent masturbation by malesappears to help prevent the development of prostate cancer. Recentresearch published in the Journal of the National Cancer Institutesuggests that taking multivitamins more than seven times a week canincrease the risks of contracting the disease. This research was unableto highlight the exact vitamins responsible for this increase (almostdouble), although they suggest that vitamin A, vitamin E andbeta-carotene may lie at its heart. It is advised that those takingmultivitamins never exceed the stated daily dose on the label.Scientists recommend a healthy, well balanced diet rich in fiber, and toreduce intake of meat. A 2007 study published in the Journal of theNational Cancer Institute found that men eating cauliflower, broccoli,or one of the other cruciferous vegetables, more than once a week were40% less likely to develop prostate cancer than men who rarely ate thosevegetables. Scientists believe the reason for this phenomenon has to dowith a phytochemical called Diindolylmethane in these vegetables thathas anti-androgenic and immune modulating properties. This compound iscurrently under investigation by the National Cancer Institute as anatural therapeutic for prostate cancer.

C. Breast Cancer

Breast cancer refers to cancers originating from breast tissue, mostcommonly from the inner lining of milk ducts or the lobules that supplythe ducts with milk. Cancers originating from ducts are known as ductalcarcinomas; those originating from lobules are known as lobularcarcinomas. There are many different types of breast cancer, withdifferent stages (spread), aggressiveness, and genetic makeup; survivalvaries greatly depending on those factors. Computerized models areavailable to predict survival. With best treatment and dependent onstaging, 10-year disease-free survival varies from 98% to 10%. Treatmentincludes surgery, drugs (hormonal therapy and chemotherapy), andradiation.

Worldwide, breast cancer comprises 10.4% of all cancer incidence amongwomen, making it the second most common type of non-skin cancer (afterlung cancer) and the fifth most common cause of cancer death. In 2004,breast cancer caused 519,000 deaths worldwide (7% of cancer deaths;almost 1% of all deaths). Breast cancer is about 100 times more commonin women than in men, although males tend to have poorer outcomes due todelays in diagnosis.

Some breast cancers require the hormones estrogen and progesterone togrow, and have receptors for those hormones. After surgery those cancersare treated with drugs that interfere with those hormones, usuallytamoxifen, and with drugs that shut off the production of estrogen inthe ovaries or elsewhere; this may damage the ovaries and end fertility.After surgery, low-risk, hormone-sensitive breast cancers may be treatedwith hormone therapy and radiation alone. Breast cancers without hormonereceptors, or which have spread to the lymph nodes in the armpits, orwhich express certain genetic characteristics, are higher-risk, and aretreated more aggressively. One standard regimen, popular in the U.S., iscyclophosphamide plus doxorubicin (Adriamycin), known as CA; these drugsdamage DNA in the cancer, but also in fast-growing normal cells wherethey cause serious side effects. Sometimes a taxane drug, such asdocetaxel, is added, and the regime is then known as CAT; taxane attacksthe microtubules in cancer cells. An equivalent treatment, popular inEurope, is cyclophosphamide, methotrexate, and fluorouracil (CMF).Monoclonal antibodies, such as trastuzumab (Herceptin), are used forcancer cells that have the HER2 mutation. Radiation is usually added tothe surgical bed to control cancer cells that were missed by thesurgery, which usually extends survival, although radiation exposure tothe heart may cause damage and heart failure in the following years.

While screening techniques (which are further discussed below) areuseful in determining the possibility of cancer, a further testing isnecessary to confirm whether a lump detected on screening is cancer, asopposed to a benign alternative such as a simple cyst.

In a clinical setting, breast cancer is commonly diagnosed using a“triple test” of clinical breast examination (breast examination by atrained medical practitioner), mammography, and fine needle aspirationcytology. Both mammography and clinical breast exam, also used forscreening, can indicate an approximate likelihood that a lump is cancer,and may also identify any other lesions. Fine Needle Aspiration andCytology (FNAC), which may be done in a doctor's office using localanaesthetic if required, involves attempting to extract a small portionof fluid from the lump. Clear fluid makes the lump highly unlikely to becancerous, but bloody fluid may be sent off for inspection under amicroscope for cancerous cells. Together, these three tools can be usedto diagnose breast cancer with a good degree of accuracy.

Other options for biopsy include core biopsy, where a section of thebreast lump is removed, and an excisional biopsy, where the entire lumpis removed.

In addition vacuum-assisted breast biopsy (VAB) may help diagnose breastcancer among patients with a mammographically detected breast in womenaccording to a systematic review. In this study, summary estimates forvacuum assisted breast biopsy in diagnosis of breast cancer were asfollows sensitivity was 98.1% with 95% CI=0.972-0.987 and specificitywas 100% with 95% CI=0.997-0.999. However underestimate rates ofatypical ductal hyperplasia (ADH) and ductal carcinoma in situ (DCIS)were 20.9% with 95% CI=0.177-0.245 and 11.2% with 95% CI=0.098-0.128respectively.

Breast cancer screening refers to testing otherwise-healthy women forbreast cancer in an attempt to achieve an earlier diagnosis. Theassumption is that early detection will improve outcomes. A number ofscreening test have been employed including: clinical and self breastexams, mammography, genetic screening, ultrasound, and magneticresonance imaging.

A clinical or self breast exam involves feeling the breast for lumps orother abnormalities. Research evidence does not support theeffectiveness of either type of breast exam, because by the time a lumpis large enough to be found it is likely to have been growing forseveral years and will soon be large enough to be found without an exam.Mammographic screening for breast cancer uses x-rays to examine thebreast for any uncharacteristic masses or lumps. In women at high risk,such as those with a strong family history of cancer, mammographyscreening is recommended at an earlier age and additional testing mayinclude genetic screening that tests for the BRCA genes and/or magneticresonance imaging.

Breast cancer is sometimes treated first with surgery, and then withchemotherapy, radiation, or both. Treatments are given with increasingaggressiveness according to the prognosis and risk of recurrence. Stage1 cancers (and DCIS) have an excellent prognosis and are generallytreated with lumpectomy with or without chemotherapy or radiation.Although the aggressive HER2+ cancers should also be treated with thetrastuzumab (Herceptin) regime. Stage 2 and 3 cancers with aprogressively poorer prognosis and greater risk of recurrence aregenerally treated with surgery (lumpectomy or mastectomy with or withoutlymph node removal), radiation (sometimes) and chemotherapy (plustrastuzumab for HER2+ cancers). Stage 4, metastatic cancer, (i.e.,spread to distant sites) is not curable and is managed by variouscombinations of all treatments from surgery, radiation, chemotherapy andtargeted therapies. These treatments increase the median survival timeof stage 4 breast cancer by about 6 months.

D. Ovarian Cancer

Ovarian cancer is a cancerous growth arising from different parts of theovary. Most (>90%) ovarian cancers are classified as “epithelial” andwere believed to arise from the surface (epithelium) of the ovary.However, recent evidence suggests that the Fallopian tube could also bethe source of some ovarian cancers. Since the ovaries and tubes areclosely related to each other, it is hypothesized that these cells canmimic ovarian cancer. Other types arise from the egg cells (germ celltumor) or supporting cells (sex cord/stromal).

In 2004, in the United States, 25,580 new cases were diagnosed and16,090 women died of ovarian cancer. The risk increases with age anddecreases with pregnancy. Lifetime risk is about 1.6%, but women withaffected first-degree relatives have a 5% risk. Women with a mutatedBRCA1 or BRCA2 gene carry a risk between 25% and 60% depending on thespecific mutation. Ovarian cancer is the fifth leading cause of deathfrom cancer in women and the leading cause of death from gynecologicalcancer.

Ovarian cancer causes non-specific symptoms. Early diagnosis wouldresult in better survival, on the assumption that stage I and II cancersprogress to stage III and IV cancers (but this has not been proven).Most women with ovarian cancer report one or more symptoms such asabdominal pain or discomfort, an abdominal mass, bloating, back pain,urinary urgency, constipation, tiredness and a range of othernon-specific symptoms, as well as more specific symptoms such as pelvicpain, abnormal vaginal bleeding or involuntary weight loss. There can bea build-up of fluid (ascites) in the abdominal cavity.

Diagnosis of ovarian cancer starts with a physical examination(including a pelvic examination), a blood test (for CA-125 and sometimesother markers), and transvaginal ultrasound. The diagnosis must beconfirmed with surgery to inspect the abdominal cavity, take biopsies(tissue samples for microscopic analysis) and look for cancer cells inthe abdominal fluid. Treatment usually involves chemotherapy andsurgery, and sometimes radiotherapy.

In most cases, the cause of ovarian cancer remains unknown. Older women,and in those who have a first or second degree relative with thedisease, have an increased risk. Hereditary forms of ovarian cancer canbe caused by mutations in specific genes (most notably BRCA1 and BRCA2,but also in genes for hereditary nonpolyposis colorectal cancer).Infertile women and those with a condition called endometriosis, thosewho have never been pregnant and those who use postmenopausal estrogenreplacement therapy are at increased risk. Use of combined oralcontraceptive pills is a protective factor. The risk is also lower inwomen who have had their uterine tubes blocked surgically (tuballigation).

Ovarian cancer is classified according to the histology of the tumor,obtained in a pathology report. Histology dictates many aspects ofclinical treatment, management, and prognosis. Surfaceepithelial-stromal tumour, also known as ovarian epithelial carcinoma,is the most common type of ovarian cancer. It includes serous tumour,endometrioid tumor and mucinous cystadenocarcinoma. Sex cord-stromaltumor, including estrogen-producing granulosa cell tumor and virilizingSertoli-Leydig cell tumor or arrhenoblastoma, accounts for 8% of ovariancancers. Germ cell tumor accounts for approximately 30% of ovariantumors but only 5% of ovarian cancers, because most germ cell tumors areteratomas and most teratomas are benign (see Teratoma). Germ cell tumortends to occur in young women and girls. The prognosis depends on thespecific histology of germ cell tumor, but overall is favorable. Mixedtumors, containing elements of more than one of the above classes oftumor histology.

Ovarian cancer can also be a secondary cancer, the result of metastasisfrom a primary cancer elsewhere in the body. Seven percent of ovariancancers are due to metastases while the rest are primary cancers. Commonprimary cancers are breast cancer and gastrointestinal cancer (a commonmistake is to name all peritoneal metastases from any gastrointestinalcancer as Krukenberg cancer, but this is only the case if it originatesfrom primary gastric cancer). Surface epithelial-stromal tumor canoriginate in the peritoneum (the lining of the abdominal cavity), inwhich case the ovarian cancer is secondary to primary peritoneal cancer,but treatment is basically the same as for primary surfaceepithelial-stromal tumor involving the peritoneum.

Ovarian cancer staging is by the FIGO staging system and usesinformation obtained after surgery, which can include a total abdominalhysterectomy, removal of (usually) both ovaries and fallopian tubes,(usually) the omentum, and pelvic (peritoneal) washings forcytopathology. The AJCC stage is the same as the FIGO stage. The AJCCstaging system describes the extent of the primary Tumor (T), theabsence or presence of metastasis to nearby lymph Nodes (N), and theabsence or presence of distant Metastasis (M).

The AJCC/TNM staging system includes three categories for ovariancancer, T, N and M. The T category contains three other subcategories,T1, T2 and T3, each of them being classified according to the placewhere the tumor has developed (in one or both ovaries, inside or outsidethe ovary). The T1 category of ovarian cancer describes ovarian tumorsthat are confined to the ovaries, and which may affect one or both ofthem. The sub-subcategory T1a is used to stage cancer that is found inonly one ovary, which has left the capsule intact and which cannot befound in the fluid taken from the pelvis. Cancer that has not affectedthe capsule, is confined to the inside of the ovaries and cannot befound in the fluid taken from the pelvis but has affected both ovariesis staged as T1b. T1c category describes a type of tumor that can affectone or both ovaries, and which has grown through the capsule of an ovaryor it is present in the fluid taken from the pelvis. T2 is a moreadvanced stage of cancer. In this case, the tumor has grown in one orboth ovaries and is spread to the uterus, fallopian tubes or otherpelvic tissues. Stage T2a is used to describe a cancerous tumor that hasspread to the uterus or the fallopian tubes (or both) but which is notpresent in the fluid taken from the pelvis. Stages T2b and T2c indicatecancer that metastasized to other pelvic tissues than the uterus andfallopian tubes and which cannot be seen in the fluid taken from thepelvis, respectively tumors that spread to any of the pelvic tissues(including uterus and fallopian tubes) but which can also be found inthe fluid taken from the pelvis. T3 is the stage used to describe cancerthat has spread to the peritoneum. This stage provides information onthe size of the metastatic tumors (tumors that are located in otherareas of the body, but are caused by ovarian cancer). These tumors canbe very small, visible only under the microscope (T3a), visible but notlarger than 2 centimeters (T3b) and bigger than 2 centimeters (T3c).

This staging system also uses N categories to describe cancers that haveor not spread to nearby lymph nodes. There are only two N categories, NOwhich indicates that the cancerous tumors have not affected the lymphnodes, and N1 which indicates the involvement of lymph nodes close tothe tumor. The M categories in the AJCC/TNM staging system provideinformation on whether the ovarian cancer has metastasized to distantorgans such as liver or lungs. M0 indicates that the cancer did notspread to distant organs and M1 category is used for cancer that hasspread to other organs of the body. The AJCC/TNM staging system alsocontains a Tx and a Nx sub-category which indicates that the extent ofthe tumor cannot be described because of insufficient data, respectivelythe involvement of the lymph nodes cannot be described because of thesame reason.

Ovarian cancer, as well as any other type of cancer, is also graded,apart from staged. The histologic grade of a tumor measures how abnormalor malignant its cells look under the microscope. There are four gradesindicating the likelihood of the cancer to spread and the higher thegrade, the more likely for this to occur. Grade 0 is used to describenon-invasive tumors. Grade 0 cancers are also referred to as borderlinetumors. Grade 1 tumors have cells that are well differentiated (lookvery similar to the normal tissue) and are the ones with the bestprognosis. Grade 2 tumors are also called moderately well differentiatedand they are made up by cells that resemble the normal tissue. Grade 3tumors have the worst prognosis and their cells are abnormal, referredto as poorly differentiated.

The signs and symptoms of ovarian cancer are most of the times absent,but when they exist they are nonspecific. In most cases, the symptomspersist for several months until the patient is diagnosed.

A prospective case-control study of 1,709 women visiting primary careclinics found that the combination of bloating, increased abdominalsize, and urinary symptoms was found in 43% of those with ovarian cancerbut in only 8% of those presenting to primary care clinics.

The exact cause is usually unknown. The risk of developing ovariancancer appears to be affected by several factors. The more children awoman has, the lower her risk of ovarian cancer. Early age at firstpregnancy, older age of final pregnancy and the use of low dose hormonalcontraception have also been shown to have a protective effect. Ovariancancer is reduced in women after tubal ligation.

The relationship between use of oral contraceptives and ovarian cancerwas shown in a summary of results of 45 case-control and prospectivestudies. Cumulatively these studies show a protective effect for ovariancancers. Women who used oral contraceptives for 10 years had about a 60%reduction in risk of ovarian cancer. (risk ratio 0.42 with statisticalsignificant confidence intervals given the large study size, notunexpected). This means that if 250 women took oral contraceptives for10 years, 1 ovarian cancer would be prevented. This is by far thelargest epidemiological study to date on this subject (45 studies, over20,000 women with ovarian cancer and about 80,000 controls).

The link to the use of fertility medication, such as Clomiphene citrate,has been controversial. An analysis in 1991 raised the possibility thatuse of drugs may increase the risk of ovarian cancer. Several cohortstudies and case-control studies have been conducted since then withoutdemonstrating conclusive evidence for such a link. It will remain acomplex topic to study as the infertile population differs in parityfrom the “normal” population.

There is good evidence that in some women genetic factors are important.Carriers of certain mutations of the BRCA1 or the BRCA2 gene are notablyat risk. The BRCA1 and BRCA2 genes account for 5%-13% of ovariancancersand certain populations (e.g. Ashkenazi Jewish women) are at ahigher risk of both breast cancer and ovarian cancer, often at anearlier age than the general population. Patients with a personalhistory of breast cancer or a family history of breast and/or ovariancancer, especially if diagnosed at a young age, may have an elevatedrisk.

A strong family history of uterine cancer, colon cancer, or othergastrointestinal cancers may indicate the presence of a syndrome knownas hereditary nonpolyposis colorectal cancer (HNPCC, also known as Lynchsyndrome), which confers a higher risk for developing ovarian cancer.Patients with strong genetic risk for ovarian cancer may consider theuse of prophylactic, i.e. preventative, oophorectomy after completion ofchildbearing.^([citation needed]) Australia being member ofInternational Cancer Genome Consortium is leading efforts to map ovariancancer's complete genome.

Ovarian cancer at its early stages(I/II) is difficult to diagnose untilit spreads and advances to later stages (III/IV). This is because mostsymptoms are non-specific and thus of little use in diagnosis.

When an ovarian malignancy is included in the list of diagnosticpossibilities, a limited number of laboratory tests are indicated. Acomplete blood count (CBC) and serum electrolyte test should be obtainedin all patients.

The serum BHCG level should be measured in any female in whom pregnancyis a possibility. In addition, serum alpha-fetoprotein (AFP) and lactatedehydrogenase (LDH) should be measured in young girls and adolescentswith suspected ovarian tumors because the younger the patient, thegreater the likelihood of a malignant germ cell tumor.

A blood test called CA-125 is useful in differential diagnosis and infollow up of the disease, but it by itself has not been shown to be aneffective method to screen for early-stage ovarian cancer due to itsunacceptable low sensitivity and specificity. However, this is the onlywidely-used marker currently available.

Current research is looking at ways to combine tumor markers proteomicsalong with other indicators of disease (i.e., radiology and/or symptoms)to improve accuracy. The challenge in such an approach is that the verylow population prevalence of ovarian cancer means that even testing withvery high sensitivity and specificity will still lead to a number offalse positive results (i.e., performing surgical procedures in whichcancer is not found intra-operatively). However, the contributions ofproteomics are still in the early stages and require further refining.Current studies on proteomics mark the beginning of a paradigm shifttowards individually tailored therapy.

A pelvic examination and imaging including CT scan and trans-vaginalultrasound are essential. Physical examination may reveal increasedabdominal girth and/or ascites (fluid within the abdominal cavity).Pelvic examination may reveal an ovarian or abdominal mass. The pelvicexamination can include a rectovaginal component for better palpation ofthe ovaries. For very young patients, magnetic resonance imaging may bepreferred to rectal and vaginal examination.

To definitively diagnose ovarian cancer, a surgical procedure to take alook into the abdomen is required. This can be an open procedure(laparotomy, incision through the abdominal wall) or keyhole surgery(laparoscopy). During this procedure, suspicious areas will be removedand sent for microscopic analysis. Fluid from the abdominal cavity canalso be analysed for cancerous cells. If there is cancer, this procedurecan also determine its spread (which is a form of tumor staging).

Women who have had children are less likely to develop ovarian cancerthan women who have not, and breastfeeding may also reduce the risk ofcertain types of ovarian cancer. Tubal ligation and hysterectomy reducethe risk and removal of both tubes and ovaries (bilateralsalpingo-oophorectomy) dramatically reduces the risk of not only ovariancancer but breast cancer also. The use of oral contraceptives (birthcontrol pills) for five years or more decreases the risk of ovariancancer in later life by 50%.

Tubal ligation is believed to decrease the chance of developing ovariancancer by up to 67% while a hysterectomy may reduce the risk of gettingovarian cancer by about one-third. Moreover, according to some studies,analgesics such as acetaminophen and aspirin seem to reduce one's risksof developing ovarian cancer. Yet, the information is not consistent andmore research needs to be carried on this matter.

Routine screening of women for ovarian cancer is not recommended by anyprofessional society—this includes the U.S. Preventive Services TaskForce, the American Cancer Society, the American College ofObstetricians and Gynecologists, and the National Comprehensive CancerNetwork. This is because no trial has shown improved survival for womenundergoing screening. Screening for any type of cancer must be accurateand reliable—it needs to accurately detect the disease and it must notgive false positive results in people who do not have cancer. As yetthere is no technique for ovarian screening that has been shown tofulfil these criteria. However in some countries such as the UK, womenwho are likely to have an increased risk of ovarian cancer (for exampleif they have a family history of the disease) can be offered individualscreening through their doctors, although this will not necessarilydetect the disease at an early stage.

Researchers are assessing different ways to screen for ovarian cancer.Screening tests that could potentially be used alone or in combinationfor routine screening include the CA-125 marker and transvaginalultrasound. Doctors can measure the levels of the CA-125 protein in awoman's blood—high levels could be a sign of ovarian cancer, but this isnot always the case. And not all women with ovarian cancer have highCA-125 levels. Transvaginal ultrasound involves using an ultrasoundprobe to scan the ovaries from inside the vagina, giving a clearer imagethan scanning the abdomen. The UK Collaborative Trial of Ovarian CancerScreening is testing a screening technique that combines CA-125 bloodtests with transvaginal ultrasound.

The purpose of screening is to diagnose ovarian cancer at an earlystage, when it is more likely to be treated successfully. However thedevelopment of the disease is not fully understood, and it has beenargued that early-stage cancers may not always develop into late-stagedisease. With any screening technique there are risks and benefits thatneed to be carefully considered, and health authorities need to assessthese before introducing any ovarian cancer screening programs.

The goal of ovarian cancer screening is to detect the disease at stageI. Several large studies are ongoing, but none have identified aneffective technique. In 2009, however, early results from the UKCollaborative Trial of Ovarian Cancer Screening (UKCTOCS) showed that atechnique combining annual CA-125 tests with ultrasound imaging did helpto detect the disease at an early stage. However, it is not yet clear ifthis approach could actually help to save lives—the full results of thetrial will be published in 2015.

Surgical treatment may be sufficient for malignant tumors that arewell-differentiated and confined to the ovary. Addition of chemotherapymay be required for more aggressive tumors that are confined to theovary. For patients with advanced disease a combination of surgicalreduction with a combination chemotherapy regimen is standard.Borderline tumors, even following spread outside of the ovary, aremanaged well with surgery, and chemotherapy is not seen as useful.

Surgery is the preferred treatment and is frequently necessary to obtaina tissue specimen for differential diagnosis via its histology. Surgeryperformed by a specialist in gynecologic oncology usually results in animproved result. Improved survival is attributed to more accuratestaging of the disease and a higher rate of aggressive surgical excisionof tumor in the abdomen by gynecologic oncologists as opposed to generalgynecologists and general surgeons.

The type of surgery depends upon how widespread the cancer is whendiagnosed (the cancer stage), as well as the presumed type and grade ofcancer. The surgeon may remove one (unilateral oophorectomy) or bothovaries (bilateral oophorectomy), the fallopian tubes (salpingectomy),and the uterus (hysterectomy). For some very early tumors (stage 1, lowgrade or low-risk disease), only the involved ovary and fallopian tubewill be removed (called a “unilateral salpingo-oophorectomy,” USO),especially in young females who wish to preserve their fertility.

In advanced malignancy, where complete resection is not feasible, asmuch tumor as possible is removed (debulking surgery). In cases wherethis type of surgery is successful (i.e., <1 cm in diameter of tumor isleft behind [“optimal debulking”]), the prognosis is improved comparedto patients where large tumor masses (>1 cm in diameter) are leftbehind. Minimally invasive surgical techniques may facilitate the saferemoval of very large (greater than 10 cm) tumors with fewercomplications of surgery.

Chemotherapy has been a general standard of care for ovarian cancer fordecades, although with highly variable protocols. Chemotherapy is usedafter surgery to treat any residual disease, if appropriate. Thisdepends on the histology of the tumor; some kinds of tumor (particularlyteratoma) are not sensitive to chemotherapy. In some cases, there may bereason to perform chemotherapy first, followed by surgery.

For patients with stage IIIC epithelial ovarian adenocarcinomas who haveundergone successful optimal debulking, a recent clinical trialdemonstrated that median survival time is significantly longer forpatient receiving intraperitoneal (IP) chemotherapy. Patients in thisclinical trial reported less compliance with IP chemotherapy and fewerthan half of the patients received all six cycles of IP chemotherapy.Despite this high “drop-out” rate, the group as a whole (including thepatients that didn't complete IP chemotherapy treatment) survived longeron average than patients who received intravenous chemotherapy alone.

Some specialists believe the toxicities and other complications of IPchemotherapy will be unnecessary with improved IV chemotherapy drugscurrently being developed.

Although IP chemotherapy has been recommended as a standard of care forthe first-line treatment of ovarian cancer, the basis for thisrecommendation has been challenged.

Radiation therapy is not effective for advanced stages because whenvital organs are in the radiation field, a high dose cannot be safelydelivered. Radiation therapy is then commonly avoided in such stages asthe vital organs may not be able to withstand the problems associatedwith these ovarian cancer treatments.

Ovarian cancer usually has a poor prognosis. It is disproportionatelydeadly because it lacks any clear early detection or screening test,meaning that most cases are not diagnosed until they have reachedadvanced stages. More than 60% of women presenting with this canceralready have stage III or stage IV cancer, when it has already spreadbeyond the ovaries. Ovarian cancers shed cells into the naturallyoccurring fluid within the abdominal cavity. These cells can thenimplant on other abdominal (peritoneal) structures, included the uterus,urinary bladder, bowel and the lining of the bowel wall omentum formingnew tumor growths before cancer is even suspected.

The five-year survival rate for all stages of ovarian cancer is 45.5%.For cases where a diagnosis is made early in the disease, when thecancer is still confined to the primary site, the five-year survivalrate is 92.7%.

E. Brain Cancer

A brain tumor is an intracranial solid neoplasm, a tumor (defined as anabnormal growth of cells) within the brain or the central spinal canal.Brain tumors include all tumors inside the cranium or in the centralspinal canal. They are created by an abnormal and uncontrolled celldivision, normally either in the brain itself (neurons, glial cells(astrocytes, oligodendrocytes, ependymal cells, myelin-producing Schwanncells), lymphatic tissue, blood vessels), in the cranial nerves, in thebrain envelopes (meninges), skull, pituitary and pineal gland, or spreadfrom cancers primarily located in other organs (metastatic tumors).

Any brain tumor is inherently serious and life-threatening because ofits invasive and infiltrative character in the limited space of theintracranial cavity. However, brain tumors (even malignant ones) are notinvariably fatal. Brain tumors or intracranial neoplasms can becancerous (malignant) or non-cancerous (benign); however, thedefinitions of malignant or benign neoplasms differs from those commonlyused in other types of cancerous or non-cancerous neoplasms in the body.Its threat level depends on the combination of factors like the type oftumor, its location, its size and its state of development. Because thebrain is well protected by the skull, the early detection of a braintumor only occurs when diagnostic tools are directed at the intracranialcavity. Usually detection occurs in advanced stages when the presence ofthe tumor has caused unexplained symptoms.

Primary (true) brain tumors are commonly located in the posteriorcranial fossa in children and in the anterior two-thirds of the cerebralhemispheres in adults, although they can affect any part of the brain.

The prognosis of brain cancer varies based on the type of cancer.

Medulloblastoma has a good prognosis with chemotherapy, radiotherapy,and surgical resection while glioblastoma multiforme has a mediansurvival of only 12 months even with aggressive chemoradiotherapy andsurgery. Brainstem gliomas have the poorest prognosis of any form ofbrain cancer, with most patients dying within one year, even withtherapy that typically consists of radiation to the tumor along withcorticosteroids. However, one type of brainstem glioma, a focal^([5])seems open to exceptional prognosis and long-term survival hasfrequently been reported.

Glioblastoma multiforme is the deadliest and most common form ofmalignant brain tumor. Even when aggressive multimodality therapyconsisting of radiotherapy, chemotherapy, and surgical excision is used,median survival is only 12-17 months. Standard therapy for glioblastomamultiforme consists of maximal surgical resection of the tumor, followedby radiotherapy between two and four weeks after the surgical procedureto remove the cancer. This is followed by chemotherapy. Most patientswith glioblastoma take a corticosteroid, typically dexamethasone, duringtheir illness to palliate symptoms. Experimental treatments includegamma-knife radiosurgery, boron neutron capture therapy and genetransfer.

Oligodendroglioma is an incurable but slowly progressive malignant braintumor. They can be treated with surgical resection, chemotherapy, and/orradiotherapy. For suspected low-grade oligodendrogliomas in selectpatients, some neuro-oncologists opt for a course of watchful waiting,with only symptomatic therapy. Tumors with the 1p/19q co-deletion havebeen found to be especially chemosensitive, and one source reportsoligodendrogliomas to be among the most chemosensitive of human solidmalignancies. A median survival of up to 16.7 years has been reportedfor low grade oligodendrogliomas.

Although there is no specific or singular clinical symptom or sign forany brain tumors, the presence of a combination of symptoms and the lackof corresponding clinical indications of infections or other causes canbe an indicator to redirect diagnostic investigation towards thepossibility of an intracranial neoplasm.

The diagnosis will often start with an interrogation of the patient toget a clear view of his medical antecedents, and his current symptoms.Clinical and laboratory investigations will serve to exclude infectionsas the cause of the symptoms. Examinations in this stage may includeophtamological, otolaryngological (or ENT) and/or electrophysiologicalexams. The use of electroencephalography (EEG) often plays a role in thediagnosis of brain tumors.

Swelling, or obstruction of the passage of cerebrospinal fluid (CSF)from the brain may cause (early) signs of increased intracranialpressure which translates clinically into headaches, vomiting, or analtered state of consciousness, and in children changes to the diameterof the skull and bulging of the fontanelles. More complex symptoms suchas endocrine dysfunctions should alarm doctors not to exclude braintumors.

A bilateral temporal visual field defect (due to compression of theoptic chiasm) or dilatation of the pupil, and the occurrence of eitherslowly evolving or the sudden onset of focal neurologic symptoms, suchas cognitive and behavioral impairment (including impaired judgment,memory loss, lack of recognition, spatial orientation disorders),personality or emotional changes, hemiparesis, hypoesthesia, aphasia,ataxia, visual field impairment, impaired sense of smell, impairedhearing, facial paralysis, double vision, or more severe symptoms suchas tremors, paralysis on one side of the body hemiplegia, or (epileptic)seizures in a patient with a negative history for epilepsy, should raisethe possibility of a brain tumor.

Imaging plays a central role in the diagnosis of brain tumors. Earlyimaging methods—invasive and sometimes dangerous—such aspneumoencephalography and cerebral angiography, have been abandoned inrecent times in favor of non-invasive, high-resolution techniques, suchas computed tomography (CT)-scans and especially magnetic resonanceimaging (MM). Neoplasms will often show as differently colored masses(also referred to as processes) in CT or MRI results.

Benign brain tumors often show up as hypodense (darker than braintissue) mass lesions on cranial CT-scans. On MRI, they appear eitherhypo- (darker than brain tissue) or isointense (same intensity as braintissue) on Tl-weighted scans, or hyperintense (brighter than braintissue) on T2-weighted MRI, although the appearance is variable.

Contrast agent uptake, sometimes in characteristic patterns, can bedemonstrated on either CT or MRI-scans in most malignant primary andmetastatic brain tumors. Perifocal edema, or pressure-areas, or wherethe brain tissue has been compressed by an invasive process also appearshyperintense on T2-weighted MM might indicate the presence a diffuseneoplasm (unclear outline). This is because these tumors disrupt thenormal functioning of the blood-brain barrier and lead to an increase inits permeability. However it is not possible to diagnose high versus lowgrade gliomas based on enhancement pattern alone.

Glioblastoma multiforme and anaplastic astrocytoma have been associatedwith the genetic acute hepatic porphyrias (PCT, AIP, HCP and VP),including positive testing associated with drug refractory seizures.Unexplained complications associated with drug treatments with thesetumors should alert physicians to an undiagnosed neurological porphyria.

The definitive diagnosis of brain tumor can only be confirmed byhistological examination of tumor tissue samples obtained either bymeans of brain biopsy or open surgery. The histological examination isessential for determining the appropriate treatment and the correctprognosis. This examination, performed by a pathologist, typically hasthree stages: interoperative examination of fresh tissue, preliminarymicroscopic examination of prepared tissues, and followup examination ofprepared tissues after immunohistochemical staining or genetic analysis.

When a brain tumor is diagnosed, a medical team will be formed to assessthe treatment options presented by the leading surgeon to the patientand his/her family. Given the location of primary solid neoplasms of thebrain in most cases a “do-nothing” option is usually not presented.Neurosurgeons take the time to observe the evolution of the neoplasmbefore proposing a management plan to the patient and his/her relatives.These various types of treatment are available depending on neoplasmtype and location and may be combined to give the best chances ofsurvival: surgery: complete or partial ressection of the tumor with theobjective of removing as many tumor cells as possible; radiotherapy; andchemotherapy, with the aim of killing as many as possible of cancerouscells left behind after surgery and of putting remaining tumor cellsinto a nondividing, sleeping state for as long as possible.

Survival rates in primary brain tumors depend on the type of tumor, age,functional status of the patient, the extent of surgical tumor removaland other factors specific to each case.

The primary and most desired course of action described in medicalliterature is surgical removal (resection) via craniotomy. Minimallyinvasive techniques are being studied but are far from being commonpractice. The prime remediating objective of surgery is to remove asmany tumor cells as possible, with complete removal being the bestoutcome and cytoreduction (“debulking”) of the tumor otherwise. In somecases access to the tumor is impossible and impedes or prohibitssurgery.

Many meningiomas, with the exception of some tumors located at the skullbase, can be successfully removed surgically. Most pituitary adenomascan be removed surgically, often using a minimally invasive approachthrough the nasal cavity and skull base (trans-nasal, trans-sphenoidalapproach). Large pituitary adenomas require a craniotomy (opening of theskull) for their removal. Radiotherapy, including stereotacticapproaches, is reserved for inoperable cases.

Several current research studies aim to improve the surgical removal ofbrain tumors by labeling tumor cells with a chemical (5-aminolevulinicacid) that causes them to fluoresce. Post-operative radiotherapy andchemotherapy are integral parts of the therapeutic standard formalignant tumors. Radiotherapy may also be administered in cases of“low-grade” gliomas, when a significant tumor burden reduction could notbe achieved surgically.

Any person undergoing brain surgery may suffer from epileptic seizures.Seizures can vary from absences to severe tonic-clonic attacks.Medication is prescribed and administered to minimize or eliminate theoccurrence of seizures.

Multiple metastatic tumors are generally treated with radiotherapy andchemotherapy rather than surgery. the prognosis in such cases isdetermined by the primary tumor, but is generally poor.

The goal of radiation therapy is to selectively kill tumor cells whileleaving normal brain tissue unharmed. In standard external beamradiation therapy, multiple treatments of standard-dose “fractions” ofradiation are applied to the brain. This process is repeated for a totalof 10 to 30 treatments, depending on the type of tumor. This additionaltreatment provides some patients with improved outcomes and longersurvival rates.

Radiosurgery is a treatment method that uses computerized calculationsto focus radiation at the site of the tumor while minimizing theradiation dose to the surrounding brain. Radiosurgery may be an adjunctto other treatments, or it may represent the primary treatment techniquefor some tumors.

Radiotherapy may be used following, or in some cases in place of,resection of the tumor. Forms of radiotherapy used for brain cancerinclude external beam radiation therapy, brachytherapy, and in moredifficult cases, stereotactic radiosurgery, such as Gamma knife,Cyberknife or Novalis Tx radiosurgery.

Radiotherapy is the most common treatment for secondary brain tumors.The amount of radiotherapy depends on the size of the area of the brainaffected by cancer. Conventional external beam ‘whole brain radiotherapytreatment’ (WBRT) or ‘whole brain irradiation’ may be suggested if thereis a risk that other secondary tumors will develop in the future.Stereotactic radiotherapy is usually recommended in cases involvingfewer than three small secondary brain tumors.

Patients undergoing chemotherapy are administered drugs designed to killtumor cells. Although chemotherapy may improve overall survival inpatients with the most malignant primary brain tumors, it does so inonly about 20 percent of patients. Chemotherapy is often used in youngchildren instead of radiation, as radiation may have negative effects onthe developing brain. The decision to prescribe this treatment is basedon a patient's overall health, type of tumor, and extent of the cancer.The toxicity and many side effects of the drugs, and the uncertainoutcome of chemotherapy in brain tumors puts this treatment further downthe line of treatment options with surgery and radiation therapypreferred.

A shunt is used not as a cure but to relieve symptoms by reducinghydrocephalus caused by blockage of cerebrospinal fluid.

Researchers are presently investigating a number of promising newtreatments including gene therapy, highly focused radiation therapy,immunotherapy and novel chemotherapies. A variety of new treatments arebeing made available on an investigational basis at centers specializingin brain tumor therapies.

F. Colorectal Cancer

Colorectal cancer, less formally known as bowel cancer, is a cancercharacterized by neoplasia in the colon, rectum, or vermiform appendix.Colorectal cancer is clinically distinct from anal cancer, which affectsthe anus.

Colorectal cancers start in the lining of the bowel. If left untreated,it can grow into the muscle layers underneath, and then through thebowel wall. Most begin as a small growth on the bowel wall: a colorectalpolyp or adenoma. These mushroom-shaped growths are usually benign, butsome develop into cancer over time. Localized bowel cancer is usuallydiagnosed through colonoscopy.

Invasive cancers that are confined within the wall of the colon (TNMstages I and II) are often curable with surgery, For example, in Englandand Wales over 90% of patients diagnosed at this stage will survive thedisease beyond 5 years. If left untreated, they spread to regional lymphnodes (stage III). In England and Wales, around 48% of patientsdiagnosed at this stage survive the disease beyond five years. Cancerthat metastasizes to distant sites (stage IV) is usually not curable;approximately 7% of patients in England and Wales diagnosed at thisstage survive beyond five years.

Colorectal cancer is the third most commonly diagnosed cancer in theworld, but it is more common in developed countries. More than half ofthe people who die of colorectal cancer live in a developed region ofthe world. GLOBOCAN estimated that, in 2008, 1.23 million new cases ofcolorectal cancer were clinically diagnosed, and that this type ofcancer killed more than 600,000 people.

The symptoms of colorectal cancer depend on the location of tumor in thebowel, and whether it has spread elsewhere in the body (metastasis).Most of the symptoms may occur in other diseases as well, and hence noneof the symptoms mentioned here is diagnostic of colorectal cancer.Symptoms and signs are divided into local, constitutional (affecting thewhole body) and metastatic (caused by spread to other organs).

Colorectal cancer is a disease originating from the epithelial cellslining the colon or rectum of the gastrointestinal tract, mostfrequently as a result of mutations in the Wnt signaling pathway thatartificially increase signaling activity. The mutations can be inheritedor are acquired, and must probably occur in the intestinal crypt stemcell. The most commonly mutated gene in all colorectal cancer is the APCgene, which produces the APC protein. The APC protein is a “brake” onthe accumulation of β-catenin protein; without APC, β-cateninaccumulates to high levels and translocates (moves) into the nucleus,binds to DNA, and activates the transcription of genes that are normallyimportant for stem cell renewal and differentiation but wheninappropriately expressed at high levels can cause cancer. While APC ismutated in most colon cancers, some cancers have increased β-cateninbecause of mutations in β-catenin (CTNNB1) that block its degradation,or they have mutation(s) or other genes with function analogous to APCsuch as AXIN1, AXIN2, TCF7L2, or the Naked cuticle (Nkd) gene NKD1.

Beyond the defects in the Wnt-APC-beta-catenin signaling pathway, othermutations must occur for the cell to become cancerous. The p53 protein,produced by the TP53 gene, normally monitors cell division and killscells if they have Wnt pathway defects. Eventually, a cell line acquiresa mutation in the TP53 gene and transforms the tissue from an adenomainto an invasive carcinoma.

Other apoptotic proteins commonly deactivated in colorectal cancers areTGF-β and DCC (Deleted in Colorectal Cancer). TGF-β has a deactivatingmutation in at least half of colorectal cancers. Sometimes TGF-β is notdeactivated, but a downstream protein named SMAD is. DCC commonly hasdeletion of its chromosome segment in colorectal cancer.

Some genes are oncogenes—they are overexpressed in colorectal cancer.For example, genes encoding the proteins KRAS, RAF, and PI3K, whichnormally stimulate the cell to divide in response to growth factors, canacquire mutations that result in over-activation of cell proliferation.PTEN, a tumor suppressor, normally inhibits PI3K, but can sometimesbecome mutated and deactivated.

Colorectal cancer can take many years to develop and early detection ofcolorectal cancer greatly improves the chances of a cure. The NationalCancer Policy Board of the Institute of Medicine estimated in 2003 thateven modest efforts to implement colorectal cancer screening methodswould result in a 29 percent drop in cancer deaths in 20 years. Despitethis, colorectal cancer screening rates remain low. Therefore, screeningfor the disease is recommended in individuals who are at increased risk.There are several different tests available for this purpose.

Digital rectal exam (DRE): The doctor inserts a lubricated, glovedfinger into the rectum to feel for abnormal areas. It only detectstumors large enough to be felt in the distal part of the rectum but isuseful as an initial screening test.

Fecal occult blood test (FOBT): a test for blood in the stool. Two typesof tests can be used for detecting occult blood in stools, i.e., guaiacbased (chemical test) and immunochemical. The sensitivity ofimmunochemical testing is superior to that of chemical testing withoutan unacceptable reduction in specifity.

Encoscopic diagnosis involves sigmoidoscopy, or use of a lighted probe(sigmoidoscope) is inserted into the rectum and lower colon to check forpolyps and other abnormalities, or colonoscopy, which is use of alighted probe called a colonoscope is inserted into the rectum and theentire colon to look for polyps and other abnormalities that may becaused by cancer. A colonoscopy has the advantage that if polyps arefound during the procedure they can be removed immediately. Tissue canalso be taken for biopsy. In the United States, colonoscopy or FOBT plussigmoidoscopy are the preferred screening options.

Colon cancer staging is an estimate of the amount of penetration of aparticular cancer. It is performed for diagnostic and research purposes,and to determine the best method of treatment. The systems for stagingcolorectal cancers depend on the extent of local invasion, the degree oflymph node involvement and whether there is distant metastasis.

Definitive staging can only be done after surgery has been performed andpathology reports reviewed. An exception to this principle would beafter a colonoscopic polypectomy of a malignant pedunculated polyp withminimal invasion. Preoperative staging of rectal cancers may be donewith endoscopic ultrasound. Adjunct staging of metastasis includeAbdominal Ultrasound, CT, PET Scanning, and other imaging studies.

The most common staging system is the TNM (for tumors/nodes/metastases)system, from the American Joint Committee on Cancer (AJCC). The TNMsystem assigns a number based on three categories. “T” denotes thedegree of invasion of the intestinal wall, “N” the degree of lymphaticnode involvement, and “M” the degree of metastasis. The broader stage ofa cancer is usually quoted as a number I, II, III, IV derived from theTNM value grouped by prognosis; a higher number indicates a moreadvanced cancer and likely a worse outcome.

The treatment depends on the stage of the cancer. When colorectal canceris caught at early stages (with little spread), it can be curable.However, when it is detected at later stages (when distant metastasesare present), it is less likely to be curable.

Surgery remains the primary treatment, while chemotherapy and/orradiotherapy may be recommended depending on the individual patient'sstaging and other medical factors.

Because colon cancer primarily affects the elderly, it can be achallenge to determine how aggressively to treat a particular patient,especially after surgery. Clinical trials suggest “otherwise fit”elderly patients fare well if they have adjuvant chemotherapy aftersurgery, so chronological age alone should not be a contraindication toaggressive management.

Surgeries can be categorised into curative, palliative, bypass, fecaldiversion, or open-and-close. Curative surgical treatment can be offeredif the tumor is localized. Very early cancer that develops within apolyp can often be cured by removing the polyp (i.e., polypectomy) atthe time of colonoscopy.

In colon cancer, a more advanced tumor typically requires surgicalremoval of the section of colon containing the tumor with sufficientmargins, and radical en-bloc resection of mesentery and lymph nodes toreduce local recurrence (i.e., colectomy). If possible, the remainingparts of colon are anastomosed to create a functioning colon. In caseswhen anastomosis is not possible, a stoma (artificial orifice) iscreated. Curative surgery on rectal cancer includes total mesorectalexcision (lower anterior resection) or abdominoperineal excision.

In case of multiple metastases, palliative (noncurative) resection ofthe primary tumor is still offered to reduce further morbidity caused bytumor bleeding, invasion, and its catabolic effect. Surgical removal ofisolated liver metastases is, however, common and may be curative inselected patients; improved chemotherapy has increased the number ofpatients who are offered surgical removal of isolated liver metastases.

If the tumor invaded into adjacent vital structures, which makesexcision technically difficult, the surgeons may prefer to bypass thetumor (ileotransverse bypass) or to do a proximal fecal diversionthrough a stoma.

The worst case would be an “open-and-close” surgery, when surgeons findthe tumor unresectable and the small bowel involved; any more proceduresare thought by some to do more harm than good to the patient. This isuncommon with the advent of laparoscopy and better radiological imaging.Most of these cases formerly subjected to “open and close” proceduresare now diagnosed in advance and surgery avoided.

Laparoscopic-assisted colectomy is a minimally invasive technique thatcan reduce the size of the incision and may reduce postoperative pain.

As with any surgical procedure, colorectal surgery may result incomplications, including wound infection, dehiscence (bursting of wound)or hernia, anastomosis breakdown, leading to abscess or fistulaformation, and/or peritonitis, bleeding with or without hematomaformation, adhesions resulting in bowel obstruction. A 5-year study ofpatients who had surgery in 1997 found the risk of hospital readmissionto be 15% after panproctocolectomy, 9% after total colectomy, and 11%after ileostomy, adjacent organ injury; most commonly to the smallintestine, ureters, spleen, or bladder, and cardiorespiratorycomplications, such as myocardial infarction, pneumonia, arrythmia, andpulmonary embolism.

Chemotherapy is used to reduce the likelihood of metastasis developing,shrink tumor size, or slow tumor growth. Chemotherapy is often appliedafter surgery (adjuvant), before surgery (neoadjuvant), or as theprimary therapy (palliative). The treatments listed here have been shownin clinical trials to improve survival and/or reduce mortality rate, andhave been approved for use by the US Food and Drug Administration. Incolon cancer, chemotherapy after surgery is usually only given if thecancer has spread to the lymph nodes (Stage III).

Chemotherapy for metastatic disease. Commonly used first linechemotherapy regimens involve the combination of infusional5-fluorouracil, leucovorin, and oxaliplatin (FOLFOX) with bevacizumab orinfusional 5-fluorouracil, leucovorin, and irinotecan (FOLFIRI) withbevacizumab or the same chemotherapy drug combinations with cetuximab inKRAS wild-type tumors.

At the 2008 annual meeting of the American Society of Clinical Oncology,researchers announced that colorectal cancer patients that have amutation in the KRAS gene do not respond to certain therapies, thosethat inhibit the epidermal growth factor receptor (EGFR)—namely Erbitux(cetuximab) and Vectibix (panitumumab). Following recommendations byASCO, patients should now be tested for the KRAS gene mutation beforebeing offered these EGFR-inhibiting drugs. In July 2009, the US Food andDrug Administration (FDA) updated the labels of two anti-EGFR monoclonalantibody drugs (panitumumab (Vectibix) and cetuximab (Erbitux))indicated for treatment of metastatic colorectal cancer to includeinformation about KRAS mutations. However, having the normal KRASversion does not guarantee these drugs will benefit the patient.

Radiotherapy is not used routinely in colon cancer, as it could lead toradiation enteritis, and it is difficult to target specific portions ofthe colon. It is more common for radiation to be used in rectal cancer,since the rectum does not move as much as the colon and is thus easierto target.

According to the American Cancer Society statistics in 2006, over 20% ofpatients present with metastatic (stage IV) colorectal cancer at thetime of diagnosis, and up to 25% of this group will have isolated livermetastasis that is potentially resectable. Lesions which undergocurative resection have demonstrated 5-year survival outcomes nowexceeding 50%.

Resectability of a liver metastasis is determined using preoperativeimaging studies (CT or MRI), intraoperative ultrasound, and by directpalpation and visualization during resection. Lesions confined to theright lobe are amenable to en bloc removal with a right hepatectomy(liver resection) surgery. Smaller lesions of the central or left liverlobe may sometimes be resected in anatomic “segments”, while largelesions of left hepatic lobe are resected by a procedure called hepatictrisegmentectomy. Treatment of lesions by smaller, nonanatomic “wedge”resections is associated with higher recurrence rates. Some lesionswhich are not initially amenable to surgical resection may becomecandidates if they have significant responses to preoperativechemotherapy or immunotherapy regimens. Lesions which are not amenableto surgical resection for cure can be treated with modalities includingradio-frequency ablation (RFA), cryoablation, and chemoembolization.

Patients with colon cancer and metastatic disease to the liver may betreated in either a single surgery or in staged surgeries (with thecolon tumor traditionally removed first) depending upon the fitness ofthe patient for prolonged surgery, the difficulty expected with theprocedure with either the colon or liver resection, and the comfort ofthe surgery performing potentially complex hepatic surgery.

A study published in 2009 found that aspirin reduces risk of colorectalneoplasia in randomized trials, and inhibits tumor growth and metastasesin animal models. The influence of aspirin on survival after diagnosisof colorectal cancer is unknown. Several reports, including aprospective cohort of 1,279 people diagnosed with stages I-III(non-metastatic) colorectal cancer, have suggested a significantimprovement in cancer-specific survival in a subset of patients usingaspirin.

Cimetidine is being investigated in Japan as an adjuvant foradenocarcinomas, including for stage III and stage IV colorectal cancersbiomarked with overexpressed sialyl Lewis X and A epitopes. Multiplesmall trials suggest a significant survival improvement in the subset ofpatients with the sLeX and sLeA biomarkers that take cimetidinetreatment perioperatively, through several mechanisms.

Cancer diagnosis very often results in an enormous change in thepatient's psychological wellbeing. Various support resources areavailable from hospitals and other agencies, which provide counseling,social service support, cancer support groups, and other services. Theseservices help to mitigate some of the difficulties of integratingpatients' medical complications into other parts of their lives.

G. Benign Prostatic Hyperplasia

Benign prostatic hyperplasia (BPH) also known as benign prostatichypertrophy (technically a misnomer), benign enlargement of the prostate(BEP), and adenofibromyomatous hyperplasia, refers to the increase insize of the prostate.

To be accurate, the process is one of hyperplasia rather thanhypertrophy, but the nomenclature is often interchangeable, even amongsturologists. It is characterized by hyperplasia of prostatic stromal andepithelial cells, resulting in the formation of large, fairly discretenodules in the periurethral region of the prostate. When sufficientlylarge, the nodules compress the urethral canal to cause partial, orsometimes virtually complete, obstruction of the urethra, whichinterferes the normal flow of urine. It leads to symptoms of urinaryhesitancy, frequent urination, dysuria (painful urination), increasedrisk of urinary tract infections, and urinary retention. Althoughprostate specific antigen levels may be elevated in these patientsbecause of increased organ volume and inflammation due to urinary tractinfections, BPH is not considered to be a premalignant lesion.

Adenomatous prostatic growth is believed to begin at approximately age30 years. An estimated 50% of men have histologic evidence of BPH by age50 years and 75% by age 80 years. In 40-50% of these patients, BPHbecomes clinically significant.

Benign prostatic hyperplasia symptoms are classified as storage orvoiding. Storage symptoms include urinary frequency, urgency (compellingneed to void that cannot be deferred), urgency incontinence, and voidingat night (nocturia). Voiding symptoms include urinary stream, hesitancy(needing to wait for the stream to begin), intermittency (when thestream starts and stops intermittently), straining to void, anddribbling. Pain and dysuria are usually not present. These storage andvoiding symptoms are evaluated using the International Prostate SymptomScore (IPSS) questionnaire, designed to assess the severity of BPH.

BPH can be a progressive disease, especially if left untreated.Incomplete voiding results in stasis of bacteria in the bladder residueand an increased risk of urinary tract infection. Urinary bladder stonesare formed from the crystallization of salts in the residual urine.Urinary retention, termed acute or chronic, is another form ofprogression. Acute urinary retention is the inability to void, while inchronic urinary retention the residual urinary volume graduallyincreases, and the bladder distends. Some patients that suffer fromchronic urinary retention may eventually progress to renal failure, acondition termed obstructive uropathy.

Androgens (testosterone and related hormones) are considered to play apermissive role in BPH by most experts. This means that androgens haveto be present for BPH to occur, but do not necessarily directly causethe condition. This is supported by the fact that castrated boys do notdevelop BPH when they age. On the other hand, administering exogenoustestosterone is not associated with a significant increase in the riskof BPH symptoms. Dihydrotestosterone (DHT), a metabolite oftestosterone, is a critical mediator of prostatic growth. DHT issynthesized in the prostate from circulating testosterone by the actionof the enzyme 5α-reductase, type 2. This enzyme is localized principallyin the stromal cells; hence, those cells are the main site for thesynthesis of DHT.

DHT can act in an autocrine fashion on the stromal cells or in paracrinefashion by diffusing into nearby epithelial cells. In both of these celltypes, DHT binds to nuclear androgen receptors and signals thetranscription of growth factors that are mitogenic to the epithelial andstromal cells. DHT is 10 times more potent than testosterone because itdissociates from the androgen receptor more slowly. The importance ofDHT in causing nodular hyperplasia is supported by clinical observationsin which an inhibitor of 5α-reductase is given to men with thiscondition. Therapy with 5α-reductase inhibitor markedly reduces the DHTcontent of the prostate and, in turn, reduces prostate volume and, inmany cases, BPH symptoms.

Testosterone promotes prostate cell proliferation, but relatively lowlevels of serum testosterone are found in patients with BPH. One smallstudy has shown that medical castration lowers the serum and prostatehormone levels unevenly, having less effect on testosterone anddihydrotestosterone levels in the prostate.

While there is some evidence that estrogen may play a role in theetiology of BPH, this effect appears to be mediated mainly through localconversion of estrogen to androgens in the prostate tissue rather than adirect effect of estrogen itself. In canine in vivo studies castration,which significantly reduced androgen levels but left estrogen levelsunchanged, caused significant atrophy of the prostate. Studies lookingfor a correlation between prostatic hyperplasia and serum estrogenlevels in humans have generally shown none.

On a microscopic level, BPH can be seen in the vast majority of men asthey age, in particular over the age of 70 years, around the world.However, rates of clinically significant, symptomatic BPH varydramatically depending on lifestyle. Men that lead a western lifestylehave a much higher incidence of symptomatic BPH than men that lead atraditional or rural lifestyle. This is confirmed by research in Chinashowing that men in rural areas have very low rates of clinical BPH,while men living in cities adopting a western lifestyle have askyrocketing incidence of this condition, though it is still below ratesseen in the West.

Rectal examination (palpation of the prostate through the rectum) mayreveal a markedly enlarged prostate, usually affecting the middle lobe.Often, blood tests are performed to rule out prostatic malignancy:Elevated prostate specific antigen (PSA) levels needs furtherinvestigations such as reinterpretation of PSA results, in terms of PSAdensity and PSA free percentage, rectal examination and transrectalultrasonography. These combined measures can provide early detection.Ultrasound examination of the testicles, prostate, and kidneys is oftenperformed, again to rule out malignancy and hydronephrosis. Screeningand diagnostic procedures for BPH are similar to those used for prostatecancer

Medication is often prescribed as the first treatment option, there aremany patients who do not achieve success with this line of treatment.Those patients may not achieve sustained improvement in symptoms or theymay stop taking the medication because of side-effects. There areoptions for treatment in a urologist's office before proceeding tosurgery. The two most common types of office-based therapies aretransurethral microwave thermotherapy (TUMT) and transurethral needleablation (TUNA). Both of these procedures rely on delivering enoughenergy to create sufficient heat to cause cell death (necrosis) in theprostate. The goal of the therapies is to cause enough necrosis so that,when the dead tissue is reabsorbed by the body, the prostate shrinks,relieving the obstruction of the urethra. These procedures are typicallyperformed with local anesthesia, and the patient returns home the sameday. Some urologists have studied and published long-term data on theoutcomes of these procedures, with data out to five years. The mostrecent American Urological Association (AUA) Guidelines for theTreatment of BPH in 2003 lists minimally invasive therapies includingTUMT and TUNA as acceptable alternatives for certain patients with BPH.

Transurethral microwave therapy (TUMT) was originally approved by theFDA in 1996, with the first generation system by EDAP Technomed. Since1996, other companies have received FDA approval for TUMT devices,including Urologix, Dornier, Thermatrix, Celsion, and Prostalund.Multiple clinical studies have been published on TUMT. The generalprinciple underlying all the devices is that a microwave antenna thatresides in a urethral catheter is placed in the intraprostatic area ofthe urethra. The catheter is connected to a control box outside of thepatient's body and is energized to emit microwave radiation into theprostate to heat the tissue and cause necrosis. It is a one-timetreatment that takes approximately 30 minutes to 1 hour, depending onthe system used. It takes approximately 4 to 6 weeks for the damagedtissue to be reabsorbed into the patient's body. Some of the devicesincorporate circulating coolant through the treatment area with theintent of preserving the urethra while the microwave energy heats theprostatic tissue surrounding the urethra.

Transurethral needle ablation (TUNA) operates with a different type ofenergy, radio frequency (RF) energy, but is designed along the samepremise as TUMT devices, that the heat the device generates will causenecrosis of the prostatic tissue and shrink the prostate. The TUNAdevice is inserted into the urethra using a rigid scope much like acystoscope. The energy is delivered into the prostate using two needlesthat emerge from the sides of the device, through the urethral wall andinto the prostate. The needle-based ablation devices are very effectiveat heating a localized area to a high enough temperature to causenecrosis. The treatment is typically performed in one session, but mayrequire multiple sticks of the needles depending on the size of theprostate.

If medical treatment fails, and the patient elects not to tryoffice-based therapies or the physician determines the patient is abetter candidate for transurethral resection of prostate (TURP), surgerymay need to be performed. In general, TURP is still considered the goldstandard of prostate interventions for patients that require aprocedure. This involves removing (part of) the prostate through theurethra. There are also a number of new methods for reducing the size ofan enlarged prostate, some of which have not been around long enough tofully establish their safety or side-effects. These include variousmethods to destroy or remove part of the excess tissue while trying toavoid damaging what remains. Transurethral electrovaporization of theprostate (TVP), laser TURP, visual laser ablation (VLAP), ethanolinjection, and others are studied as alternatives.

Newer techniques involving lasers in urology have emerged in the last5-10 years, starting with the VLAP technique involving the Nd:YAG laserwith contact on the prostatic tissue. A similar technology calledPhotoselective Vaporization of the Prostate (PVP) with the GreenLight(KTP) laser have emerged very recently. This procedure involves ahigh-power 80-watt KTP laser with a 550-micrometre laser fiber insertedinto the prostate. This fiber has an internal reflection with a70-degree deflecting angle. It is used to vaporize the tissue to theprostatic capsule. KTP lasers target haemoglobin as the chromophore andtypically have a penetration depth of 2.0 mm (four times deeper thanholmium).

Another procedure termed Holmium Laser Ablation of the Prostate (HoLAP)has also been gaining acceptance around the world. Like KTP, thedelivery device for HoLAP procedures is a 550 um disposable side-firingfiber that directs the beam from a high-power 100-watt laser at a70-degree angle from the fiber axis. The holmium wavelength is 2,140 nm,which falls within the infrared portion of the spectrum and is invisibleto the naked eye. Whereas KTP relies on haemoglobin as a chromophore,water within the target tissue is the chromophore for Holmium lasers.The penetration depth of Holmium lasers is <0.5 mm, avoidingcomplications associated with tissue necrosis often found with thedeeper penetration and lower peak powers of KTP.

HoLEP, Holmium Laser Enucleation of the Prostate, is another Holmiumlaser procedure reported to carry fewer risks compared with either TURPor open prostatectomy. HoLEP is largely similar to the HoLAP procedure;the main difference is that this procedure is typically performed onlarger prostates. Instead of ablating the tissue, the laser cuts aportion of the prostate, which is then cut into smaller pieces andflushed with irrigation fluid. As with the HoLAP procedure, there islittle bleeding during or after the procedure.

Both wavelengths, KTP and Holmium, ablate approximately one to two gramsof tissue per minute.

III. Examples

The following examples are included to demonstrate preferred embodimentsof the invention. It should be appreciated by those of skill in the artthat the techniques disclosed in the examples which follow representtechniques discovered by the inventor to function well in the practiceof the invention, and thus can be considered to constitute preferredmodes for its practice. However, those of skill in the art should, inlight of the present disclosure, appreciate that many changes can bemade in the specific embodiments which are disclosed and still obtain alike or similar result without departing from the spirit and scope ofthe invention.

RESULTS

Since AR signaling may require LXXLL (SEQ ID NO: 1) structural motifs,the inventors initially evaluated LXXLL (SEQ ID NO: 1) structural motifson PELP1 as potential targets. PELP1 contains 10 such LXXLL (SEQ IDNO: 1) motifs that adopt a helical structure when it is bound to nuclearreceptors. The rigid and pre-organized structure of a tris-benzamidefacilitates the placement of 3 functional groups corresponding to theamino acids found at the i, i+4, and i+7 positions in an α-helix.Conversely, a bis-benzamide scaffold can present 2 side chains of theamino acids found at the i and i+4 positions by using its 2 substituents(R₁₋₂). The inventors decided to design their initial peptidomimetic asa generic LXXXL (SEQ ID NO: 3) peptidomimetic to potentially target all10 PELP1 LXXLL (SEQ ID NO: 1) motifs. The design of the initialpeptidomimetic utilized a Monte Carlo conformational search (5,000steps) using a MM3 force field implemented into the software, and showedthat 2 functional groups (R₁₋₂) in the lowest-energy conformation arewell overlaid on the corresponding side chains of a helix. Thefunctional organization and presentation of these leucines on one sideof a helix was confirmed by molecular modeling using MacroModel (version9, Schrödinger, New York, N.Y.).

X-ray crystal structure of a short peptide derived from an LXXLL (SEQ IDNO: 1) sequence bound to AR showed that the LXXLL (SEQ ID NO: 1) motifadopts an α-helical structure and the side chains of the three leucinesat the i, i+3, and i+4 positions interact with the hydrophobic pocket inthe AF2 domain of AR (FIG. 4A). Since the rigid and pre-organizedstructure of a bis-benzamide scaffold can place two substituents as theside chains of the amino acid residues at the i and i+4 positions of ahelix appear, the inventors designed bis-benzamide-based peptidomimeticsto potentially target all ten LXXLL (SEQ ID NO: 1) motifs in PELP1. Thedesign of the LXXLL (SEQ ID NO: 1) peptidomimetics also allows theblockade of interaction between AR and other cofactor proteins thatinteract with AR through this nuclear receptor box.

Two isobutyl groups of the bis-benzamide D2 was designed to mimic theside chains of the two leucines at the i and i+4 positions of the LXXLL(SEQ ID NO: 1) motif, organizing hydrophobic surface for AR interaction.As shown in FIG. 4D, the lowest energy conformation demonstrated thatthe two isobutyl groups in D2 were well overlaid over the side chains oftwo leucines. The initial compound was the bis-benzamide D2, which hastwo 2 isobutyl groups to emulate the side chain groups of 2 Leu at the iand i+4 position of the LXXLL (SEQ ID NO: 1) motif, whereas a control D1contains 2 benzyl groups (FIG. 5). On the other hand, a bis-benzamidecontaining two benzyl groups (D1) was synthesized as a control (FIG. 5).Two isobutyl groups of the bis-benzamide D2 was designed to mimic theside chains of the two leucines at the i and i+4 positions of the LXXLL(SEQ ID NO: 1) motif, organizing hydrophobic surface for AR interaction.On the other hand, a bis-benzamide containing two benzyl groups (D1) wassynthesized as a control (FIG. 5).

The LXXLL (SEQ ID NO: 1) peptidomimetic D2 was stable in DMSO at roomtemperature and −70° C. over a long period of storage (60 days). Besidesthe long shelf life, D2 was remarkably found to be stable in cell lysateof LNCaP over 7 days (FIGS. 4E-F).

FIG. 6 provides confirmation that D2 was directed against the LXXLL (SEQID NO: 1) motif and was capable of blocking AR and PELP1 interaction invivo was obtained from coimmunoprecipitation experiments in LnCaP PCacells. Preincubation of PCa cells with 100 nM D2, but not D1, blockedthe ability of DHT-induced AR and PELP1 to physically interact with eachother.

FIG. 7 shows that D2 blocked AR-PELP1 interaction in a dose-dependentmanner. D2 was also able to block the DHT- and E2-induced interaction ofAR with PELP1 in LAPC4, C4-2, VCAP and CWR22v1 cells. D2 did notadversely affect the stability of either AR or PELP1. D2 was not able toaffect the interaction between AR and hsp90, a protein that lacks aLXXLL (SEQ ID NO: 1) motif on its primary structure. The ability of D2to block AR-PELP1 interaction could be overcome by transientover-expression of PELP1 in a dose-dependent manner.

FIG. 8 confirms these findings by QPCR experiment evaluating the effectof D1 and D2 on DHT-induced TMPRSS and PSA gene expression at the RNAlevel in LNCaP cells (bottom left panel) and by western blot analyses asevaluated by the effect of D1 and D2 on the expression of PSA, androgenreceptor and actin in LAPC4 cells at the protein level. Of the 341transcripts significantly upregulated by DHT, pretreatment with D2reduced the expression level of 219 genes back to baseline. Confirmationof these findings were obtained by QPCR and western blot analyses.

FIG. 9 demonstrates that D2 was able to block DHT-induced transcriptionfrom an PSA-luciferase promoter in LAPC4 cells or from a minimalARE-luciferasereporter in LNCaP, CWR22v1 and LAPC4 cell lines. Theability of D2 to block DHT-induced transcription from ARE-drivenpromoters was confirmed at the RNA level using QPCR evaluation of boththe PSA and TMPRSS promoter. Further, D2 blocked DHT-induced AR bindingon PSA promoter at evidenced by CHiP assays. At the protein level, D2,but not D1, was able to block DHT-induced expression of PSA protein.Again, the suppresion of DHT-induced transcription from an ARE could beovercome by overexpression of either AR or PELP1 (FIG. 4).Overexpression of PELP1 was able to rescue the D2-mediated suppressionof DHT-induced transcription nearly back to baseline. These dataindicated that D2 can block AR genomic signaling, at least in part byblocking AR-PELP1 interaction.

Pretreatment with D2 prevented the DHT-induced proliferation of avariety of PCa cell lines that contain AR, such as LNCaP, LAPC4, C4-2,RWPE-1, CWR22v1, VCaP, MDAPCa 2b but not AR-negative PCa cell lines suchas DU145 or PC3 whereas the control D1 did not show any activity (FIG.10). These data were confirmed using BrdU assays (CyQuant). D2 was ableto significantly reduce DHT-mediated proliferation of PCa cells in vitroin dose-dependent manner (IC₅₀ ˜40 nM) in MTT assays. The importance ofPELP1 and AR interaction on DHT-mediated proliferation of prostatecancer cells were confirmed using rescue experiments, where D2suppression of DHT-mediated proliferation was overcome by overexpressionof PELP1 in LNCaP PCa cells. Finally, the effect in xenografts showedthat D2 was biologically active in blocking AR-PELP1 interaction even invivo models.

As shown in FIG. 11, the effect of D2 on steroid-induced proliferationpathways appears to be specific, as D2 had no effect on EGF orLPA-induced proliferation of PCa cells. In this experiment, cells wereplated (2-10×103/well) in 96 well plates and subjected to androgendeprivation for 48 hours with phenol-red free RPMI and 1% charcoalstripped fetal bovine serum (CSF). Cells were then treated with eitherethanol, EGF or DHT as a positive control for 48 hours. Peptidomimeticswere added 2 hours prior to treatment. Cell proliferation was measuredusing the MTT colorimetric assay. All experiments were performed intriplicate and the average of experiments displayed.

FIG. 12 shows the effect of D2 on DHT-induced genomic activation wasspecific, as D2 had no effect on DHT-mediated non-genomic activation oferk. FIG. 13 shos that pretreatment with D2 blocked DHT-inducedtranslocation of AR-GFP to the nucleus in LnCaP cells compared to thecontrol D1 or DMSO. These findings were confirmed with biochemicalanalyses of the nuclear and cytoplasmic extracts from LnCaP cells, whichrevealed that pretreatment with D2, but not D1 or DMSO, prevents ARnuclear translocation upon addition of DHT. These data are furthercorroborated by evaluations of the endogenous AR in LAPC4 cells.

In FIG. 14, two fluorescent analogues of D2 were prepared, one byintroducing a fluorescein moiety to the C-terminus of D2 (CF1-D2) andthe other by placing it at the the N-terminus (CF2-D2). Followingincubation with these fluorescent analogues, CF2-D2, but not CF1-D2, wasshown to enter LNCaP cells. As a result, CF2-D2, but not CF1-D2, wasable to block DHT-induced proliferatin of PCa cells. These data confirmthat the peptidomimetic D2 functions by entering the PCa cells and thatwhen the peptidomimetic does not enter the cell, it has no ability toblock AR signaling. FIG. 15 shows confocal studies confirming that thepeptidomimetic CF2-D2 functions by entering the PCa cells and is widelylocalized within the cell

In FIG. 16, at higher concentrations (500 nM) D1 blocks erk activationin western blot analyses, whereas D2 blocks at lower concentrations. D2,and to a less extent D1, targets a validated target in prostate cancer,has the potential to be an AR-selective modulator, provides a novelmechanism of action, and will likely provide a sustained effect in thecontext of therapy.

FIG. 17 shows proliferation assays for each of the derivatives in FIGS.19A-N. This graph represents the effectiveness of each compound. Cellswere plated (2-10×10³/well) in 96-well plates and subjected to androgendeprivation for 48 hours with phenol-red free RPMI and 1% charcoalstripped fetal bovine serum (CSF). Cells were then treated with eitherethanol or DHT as a positive control for 48 hours Peptidomimetics wereadded 2 hours prior to treatment. Cell proliferation was measured usingthe MTT colorimetric assay. All experiments were performed in triplicateand the average of experiments displayed.

FIG. 18 shows potential modifications of the D2 peptidomimetics. FIGS.19A-N show a variety of tested compounds. FIG. 19A shows modificationsof the x and y positions reveal that substituents such as D2-4 and D2-5have maximal activity on the proliferation of prostate cancer cells invivo. FIG. 19B shows modifications of the x and y positions reveal thatsubstituents such as D2-4 has good activity on the proliferation ofprostate cancer cells in vivo. FIG. 19C shows modifications of the x andy positions reveal that substituents such as D2-CF2 and D2-5 hasexcellent activity on the proliferation of prostate cancer cells invivo. FIG. 19D shows that substituents such as D2-11, D2-12 and D2-26have good activity on the proliferation of prostate cancer cells invivo. FIG. 19E shows modifications that reveal that substituents such asD2-11, D2-23 and D2-26 have good activity on the proliferation ofprostate cancer cells in vivo. FIG. 19F shows modifications revealingthat substituents such as D2, D2-30 and D2R11N have good activity on theproliferation of prostate cancer cells in vivo (D2R11N is watersoluble). FIG. 19G shows modifications revealing that substituents suchas D2, D5-1, JHL05 and JHL04 have good activity on the proliferation ofprostate cancer cells in vivo. FIG. 19H provides modifications revealingthat substituents such as TK6, TK6-R, TK-8, TK8R. TK9, TK9R, TK11 andTK11R have good activity on the proliferation of prostate cancer cellsin vivo. FIG. 19I illustrates modifications reveal that substituentssuch as TK-ABA, TK-L2-AAC, TK-L2-AAB, TK-L2-ABB, TK-L2-ABC, TK-L2-BAA,TK-L2-BAB, TK-L2-CBB and TK-L2-CCB have good activity on theproliferation of prostate cancer cells in vivo. FIG. 19J shows thatsubstituents such as TK-ABA, TK-L2-ACA, TK-L2-ABB, TK-L2-ABC, TK-L2-BAA,TK-L2-AAC, and TK-L2-ABC have good activity on the proliferation ofprostate cancer cells in vivo. FIG. 19K shows that substituents such asR1=nButyl, and R2=nButyl, and R1=iso Butyl and R2=secButyl andR1=nPropyl and R2=isobutyl have better activity than D2 on theproliferation of prostate cancer cells in vivo. These three work atlower concentrations than D2. FIG. 19L shown modifications revealingthat substituents such as D29 has good activity on the proliferation ofprostate cancer cells in vivo. FIG. 19M illustrates modifications suchas D2 have good activity on the proliferation of prostate cancer cellsin vivo. FIG. 19N shows that substituents such as D2 and D2-47 have goodactivity on the proliferation of prostate cancer cells in vivo. FIGS.

FIG. 20 shows some of the highest activity compounds, and FIGS. 21-22show various activities for the same.

Taken together, these results clearly indicate that the functionalinteraction of AR and PELP1 appears to be critical for AR signaling andthat by blocking this interaction using rationally designed LXXLL (SEQID NO: 1) peptidomimetics, AR nuclear translocation, AR-mediated genomicsignaling and PCa cell proliferation can be affected. Peptidomimeticsimpacting this interaction are therefore useful in controlling ARsignaling.

All of the compositions and/or methods disclosed and claimed herein canbe made and executed without undue experimentation in light of thepresent disclosure. While the compositions and methods of this inventionhave been described in terms of preferred embodiments, it will beapparent to those of skill in the art that variations may be applied tothe compositions and/or methods and in the steps or in the sequence ofsteps of the method described herein without departing from the concept,spirit and scope of the invention. All such similar substitutes andmodifications apparent to those skilled in the art are deemed to bewithin the spirit, scope and concept of the invention as defined by theappended claims.

REFERENCES

The following references, to the extent that they provide exemplaryprocedural or other details supplementary to those set forth herein, arespecifically incorporated herein by reference.

-   U.S. Patent Publn. 2009/0012141-   Ahn et al., Mini-Rev. Med. Chem., 2:463-473, 2002.-   Marshall, Tetrahedron, 49:3547-3558, 1993.

What is claimed:
 1. A compound of formula (A):

wherein: R₁ and R₂ are each independently C₁-C₁₀ alkyl, C₂-C₁₀ alkenyl,C₂-C₁₀ alkynyl, C₁-C₁₅ optionally substituted arylalkyl,—(CH₂)_(n)—COOR, —(CH₂)_(n)—CONRR′, —(CH₂)_(n)—NRR′,—(CH₂)_(n)—NH(C═NH)NRR′, —(CH₂)_(n)—NRCOR′, —(CH₂)_(n)—NRCOOR′,—(CH₂)_(n)—OR, —(CH₂)_(n)—SR, —(CH₂)_(n)—SO_(m)R, —(CH₂)_(n)—PO_(m)R,wherein n and m may be any number between 0 and 6 and R and R′ may be aH, C₁-C₁₀ alkyl, C₁-C₁₀ alkenyl, C₁-C₁₀ alkynyl, or C₁-C₁₅ optionallysubstituted arylalkyl group; X is —NO₂ or —NHC(O)CH₂R₃, wherein R₃ is—NO₂, —NH₂, —Z, C₁-C₁₀ alkyl, C₁-C₁₀ alkenyl, C₁-C₁₀ alkynyl, or C₁-C₁₅arylalkyl, each of which is optionally substituted with —COOR, —CONRR′,—NRR′, —NH(C═NH)NRR′, —NRCOR′, —NRCOOR′, —OR, —SR, —SO_(nR), or—PO_(n)R, wherein n may be any number between 0 and 6 and R and R′ maybe a H, C₁-C₁₀ alkyl, C₂-C₁₀ alkenyl, C₂-C₁₀ alkynyl, or C₁-C₁₅optionally substituted arylalkyl group, and wherein Z is:

and Y is —(CH₂)_(n)CONR₄R₅, —(CH₂)_(n)NR₄R₅, —(CH₂)_(n)—NR₄R₅,—(CH₂)_(n)—NH(C═NH)NR₄R₅, —(CH₂)_(n)—NR₄COR₅, —(CH₂)_(n)—NR₄COOR₅,—(CH₂)_(n)—OR₄, —(CH₂)_(n)—SR₄, —(CH₂)_(n)—SO_(m)R₄,—(CH₂)_(n)—PO_(m)R₄, wherein n and m may be any number between 0 and 6,R₄ and R₅ are independently selected from —H, C₁-C₁₀ alkyl, C₂-C₁₀alkenyl, C₂-C₁₀ alkynyl, or C₁-C₁₅ optionally substituted arylalkylgroup; or Y is —(CH₂)_(n)COOR₄, wherein R₄ is —H or C₁-C₁₀ alkenyl. 2.The compound of claim 1, wherein X is —NO₂.
 3. The compound of claim 2,wherein R₁ and R₂ are C₁-C₁₀ alkyl, C₂-C₁₀ alkenyl, or C₂-C₁₀ alkynyl,R₁ and R₂ are optionally substituted C₁-C₁₅ arylalkyl, R₁ and R₂ are—(CH₂)_(n)—NRR′ or —(CH₂)_(n)—NH(C═NH)NRR′ groups, wherein n may be anynumber between 0 and 6 and R and R′ may be a H, C₁-C₁₀ alkyl, C₂-C₁₀alkenyl, C₂-C₁₀ alkynyl, or C₁-C₁₅ optionally substituted arylalkyl, R₁and R₂ are —(CH₂)_(n)—COOR, —(CH₂)_(n)—CONRR′, —(CH₂)_(n)—NRCOR′,—(CH₂)_(n)—NRCOOR′, —(CH₂)_(n)—SO_(m)R, —(CH₂)_(n)—PO_(m)R, wherein nand m may be any number between 0 and 6 and R and R′ may be a H, C₁-C₁₀alkyl, C₂-C₁₀ alkenyl, C₂-C₁₀ alkynyl, or C₁-C₁₅ optionally substitutedarylalkyl, R₁ and R₂ are —(CH₂)_(n)—OR, —(CH₂)_(n)—SR, wherein R may bea H, C₁-C₁₀ alkyl, C₂-C₁₀ alkenyl, C₂-C₁₀ alkynyl, or C₁-C₁₅ optionallysubstituted arylalkyl, R₁ is C₁-C₁₅ optionally substituted arylalkyl,and R₂ is C₁-C₁₀ alkyl, C₂-C₁₀ alkenyl, or C₂-C₁₀ alkynyl, R₁ is C₁-C₁₀alkyl, C₂-C₁₀ alkenyl, or C₂-C₁₀ alkynyl, and R₂ is C₁-C₁₅ optionallysubstituted arylalkyl, R₁ is —(CH₂)_(n)—NRR′ or —(CH₂)_(n)—NH(C═NH)NRR′,and R₂ is —(CH₂)_(n)—COOR, —(CH₂)_(n)—SO_(m)R, —(CH₂)_(n)—PO_(m)R,wherein n and m may be any number between 0 and 6 and R and R′ may be aH, C₁-C₁₀ alkyl, C₂-C₁₀ alkenyl, C₂-C₁₀ alkynyl, or C₁-C₁₅ optionallysubstituted arylalkyl group, or R₁ is —(CH₂)_(n)—COOR,—(CH₂)_(n)—SO_(m)R, —(CH₂)_(n)—PO_(m)R, and R₂ is —(CH₂)_(n)—NRR′ or—(CH₂)_(n)—NH(C═NH)NRR′, wherein n and m may be any number between 0 and6 and R and R′ may be a H, C₁-C₁₀ alkyl, C₂-C₁₀ alkenyl, C₂-C₁₀ alkynyl,or C₁-C₁₅ optionally substituted arylalkyl group.
 4. The compound ofclaim 1, wherein X is —NHC(O)CH₂R₃ and R₃ is —NH₂ or C₁-C₁₀ alkyl,optionally substituted with —COOH.
 5. The compound of claim 1, wherein Yis —NH₂.
 6. The compound of claim 1, wherein the compound is:


7. A pharmaceutical composition comprising a compound as shown in claim1, dispersed in a pharmaceutically acceptable carrier, buffer ordiluent.
 8. A method of inhibiting an androgen receptor (AR)-positivetumor cell comprising administering to a subject in need thereof atherapeutically sufficient amount of a compound as shown in claim
 1. 9.The method of claim 8, wherein the AR-positive tumor cell is a carcinomacell, a leukemia cell or a myeloma cell.
 10. The method of claim 9,wherein the carcinoma cell is a prostate or breast carcinoma cell.